Fillable Application - Student Housing Supplement36-10786

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Application - Student Housing Supplement36-10786

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STUDENT HOUSING SUPPLEMENTAL APPLICATION
SUBMISSION REQUIREMENTS
• Completed ACORD applications
• SOV (include auxiliary buildings & specific street address)
• Color photos (representative building &
auxiliary buildings)
• 4 year currently valued company loss runs (5 year currently
valued company loss runs for accounts over $100,000)
• Plot plan with distance of building separation
• Copy of parental guarantee
• Copy of lease
• Copy of rules and regulations
• Financials
• Evacuation Plan
• Rent Roll if Commercial / Office Occupancy
• BI worksheet if BI is requested
GENERAL APPLICANT INFORMATION
SECTION I – GENERAL ACCOUNT INFORMATION
1. What is the percentage of student occupancy? %
2. What is the percentage of “other than student occupancy”? %
3. How many total units:
4. Are there any vacant units? Yes No
If yes, how many:
5. Are pets allowed? Yes No
If yes, is there a pet park with rules posted? Yes No
6. Are students provided with written statement of community policies and rules? Yes No
7.
Are parental guarantees for both rents and damages required? Provide a copy.
Yes No
8. Is a no smoking policy in existence? Yes No
Commercial or Office Occupancy
1. Office # of office units: Square footage of office units:
Commercial # of commercial units: Square footage of commercial units:
Management
1. Is there an onsite residential manager, owner, and/or full time property manager? Yes No
2. Does onsite management specialize in student housing? Yes No
3. Is maintenance available 24/7? Yes No
SECTION II – BUILDING INFORMATION
Construction Type
1. Is the exterior covered with dryvit, EIFS or aluminum sliding? Yes No
2. If frame construction, is siding wood shake? Yes No
3. Year built / Age of building: Number of stories:
Fire Protection and Alarms
1. Smoke detectors in common areas: Hardwired Battery N/A (no common areas)
2. Smoke detectors in units: Hardwired Battery
3. Carbon monoxide detectors? Yes No
4. Local fire alarm? Yes No Central station fire alarm? Yes No
5. Annunciator panel? Yes No
6. Are there firewalls? Yes No If yes, how many:
7. What is the rating in terms of hours: Are they masonry firewalls? Yes No
8.
Do all firewalls extend to underside of roof? Please explain:
Yes No
Student Housing Supplemental
Page 1 of 7
© 2019 Philadelphia Consolidated Holding Corp.
07/2019
Applicant Name:
C/O (if applicable)
Effective date: Website address:
Cell Phone: Risk Management Contact:
Email:
Does the Applicant hire a 3
rd
party Property Manager? Yes No
a. If yes, who?
b. If yes, how long have they been managing this property?
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Is there a sprinkler system?
Yes
No
Type of sprinkler system:
Dry
Wet
If applicable, are sprinkler pipes running through the attic area insulated?
N/A
Yes
No
Classification:
NFPA 13
NFPA 13R
Other:
Areas of coverage:
Entire building
Units
Common Area
Attic
Basement
Garage
Distance to nearest responding fire department:
Roof
Roof Type:
Asphalt / Composition Shingle
If so, are any T-Lock shingles used?
Yes
No
Tile (Clay)
Tile (concrete)
Metal
Wood Shake / Shingle
Flat (tar and gravel)
Flat (Membrane)
Other:
Roof Warranty:
Years
Year of last update:
Are roofs inspected annually?
Yes
No
If yes, by whom:
Are roof replacements scheduled?
Yes
No
Do the roofs have ice shields installed?
N/A
Yes
No
If yes, how many feet:
Any ice damming history?
N/A
Yes
No
If yes, corrective action taken:
Are there any attics?
Yes
No
Is there HVAC equipment in attic space?
N/A
Yes
No
If HVAC equipment is on the roof, are there hail guards installed?
N/A
Yes
No
Heating, Ventilation and Air Conditioning (HVAC)
Are there any boilers?
Yes
No
If yes, date of last inspection (MM/YY):
Are there any fire places?
Yes
No
If yes, regular cleaning required?
Yes
No
Are there any wood stoves?
Yes
No
Is there a central HVAC?
Yes
No
If yes, provide details on any updating of HVAC services:
Means of Egress
Are there illuminated exit signs?
Yes
No
Number of exits per building:
Are all interior stairwells masonry enclosed?
Yes
No
Do all interior stairwells have fire doors?
Yes
No
Are fire doors equipped with panic hardware?
Yes
No
Are there exterior fire escapes?
Yes
No
Is there emergency lighting in hallways and stairwells?
Yes
No
Are there any elevators?
Yes
No
If yes, # of passenger:
# of freight:
Miscellaneous Building Issues
Is grilling permitted on the premises?
Yes
No
If yes, are residents allowed to bring grills on the premises?
Yes
No
Are grills provided in a centralized location and at least 15 feet from any structure?
Yes
No
Are there any known or suspected construction defects?
Yes
No
If yes, describe defect and remediation work:
Are there any outstanding insurance company risk management recommendations?
Yes
No
If yes, provide details on recommendations and work planned:
Are there any buildings built on pilings?
Yes
No
Student Housing Supplemental
Page 2 of 7
© 2019 Philadelphia Consolidated Holding Corp.
07/2019
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SECTON III – LIABILITY INFORMATION
Security N/A
Is this a gated community?
Yes
No
Please describe access:
Are there security guards at the premises daily?
Yes
No
If yes, is it:
24 hour
Evenings
Other:
If no, skip to question 8.
Indicate the number of personnel providing security services:
Employed:
Unarmed Security:
Armed Security:
Contracted:
Unarmed Security:
Armed Security:
When security is contracted to a third party, is the contractor’s general liability/law
enforcement professional liability policy required to name the Applicant as Additional
Insured?
Yes
No
If yes, does the third party maintain a minimum limit of liability coverage and indemnify the
Applicant?
Yes
No
If yes, indicate the minimum limit of liability of general / policy professional liability coverage
the Applicant requires: $
Do security personnel have arresting authority?
Yes
No
If there is employed armed security, are they trained and/or re-certified annually to the
standards required for public sector law enforcement personnel within the political
subdivision for use of weapons?
Yes
No
Are criminal background checks and psychological reviews provided for all employed
security?
Yes
No
If yes, how often are these checks and reviews conducted? Every months.
If no, explain:
Does the Applicant permit staff, volunteers, or visitors to carry open or concealed firearms
on the Applicant’s premises?
Yes
No
If the Applicant does not permit open and/or concealed carry of firearms on any premises
for which the Applicant is requesting insurance coverage, do all locations have signage
which conspicuously identifies the building as a Gun Free Zone?
Yes
No
Do security personnel store weapons on premises?
Yes
No
Do staff or employees store weapons on premises?
Yes
No
Is the premises equipped with Closed Circuit TV?
Yes
No
Clubhouse N/A
Indicate clubhouse exposures:
Cooking Facilities
Food Service
Liquor Service
Indoor Pool
Pro Shop
Convenience Store
Retail Store
Spa
Other:
Is the clubhouse rented out?
Yes
No
If yes, to whom:
Residents
Public
Is a formal rental agreement used?
Yes
No
Fitness Centers N/A
Is there an exercise/ weight room?
Yes
No
Is the fitness facility open 24 hours?
Yes
No
Is the fitness facility adequately supervised or monitored?
Yes
No
Do the fitness rooms have posted “exercise at your own risk” and proper use of equipment
signs?
Yes
No
Are the facilities used by students only?
Yes
No
Does the fitness center have tanning beds?
Yes
No
If yes, are the tanning beds using UVB bulbs?
Swimming Pools N/A
Are there any pools?
Yes
No
Are there any diving boards?
Yes
No
If yes, number of diving boards:
Highest diving board:
Are there any slides?
Yes
No
Number of slides (attach photo):
Tube
½ tube
Other:
Are there any whirlpools?
Yes
No
Can the pool be rented out for private functions?
Yes
No
Are pools completely fenced?
Yes
No
Does the pool have a self-locking / latching gate that is in proper working condition?
Yes
No
Are all doors / gates leading to the pool area locked after hours?
Yes
No
Is public access to the pool area controlled by a secure door or gate?
Yes
No
What are the hours of operations:
Yes No
Student Housing Supplemental
Page 3 of 7
© 2019 Philadelphia Consolidated Holding Corp.
07/2019
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Are lifeguards on duty during posted hours?
Yes
No
Are the hours posted?
Yes
No
Are lifeguards:
Employees
Sub-contracted
If sub-contracted, is a current certificate of insurance obtained?
Yes
No
Is a written maintenance schedule check done on all life safety features daily?
Yes
No
Who is responsible for daily maintenance?
Are “SWIM AT YOUR OWN RISK” signs posted?
Yes
No
Are pool depths marked in and around the pool area?
Yes
No
Are all swimming pools and spas compliant with Virginia Graeme Baker Pool and Spa
Safety Act?
Yes
No
If no, provide time table and action plan:
Lakes or Ponds N/A
Are there any ponds/lakes?
Yes
No
If yes, is swimming permitted?
Yes
No
If yes, is swimming restricted to designated area?
Yes
No
If yes, is the area roped off?
Yes
No
Are lifeguards on duty during posted hours?
Yes
No
Are lifeguards:
Employees
Sub-contracted
If subcontracted, is a current certificate of insurance obtained?
Yes
No
Is ice skating allowed?
Yes
No
Is fishing allowed?
Yes
No
Is non-motorized boating allowed?
Yes
No
Is motorized boating allowed?
Yes
No
Are signs posted indicating prohibited activities?
Yes
No
Maintenance and Independent Contractors
Is there any hired maintenance work done?
Yes
No
If yes, does Applicant get certificates?
Yes
No
If yes, does the independent contractor have at least $1,000,000 in liability limits?
Yes
No
Are they supervised while working?
Yes
No
If maintenance is provided, please describe below what services are provided.
SECTION IV – ABUSE AND MOLESTATION
Does the Applicant’s employment process (for employees and volunteers) include
verification of whether the individual has ever been convicted of any crime, including sex-
related or child abuse related offenses, before an offer of employment is made?
Yes
No
Does the Applicant’s state permit Applicant to do criminal background investigations?
Yes
No
If yes, does the Applicant routinely request and receive such background investigations?
Yes
No
Are Federal and State Criminal Background checks performed on:
Staff?
Yes
No
Volunteers?
Yes
No
Do any independent contractors have access to students or perform operations where they
will be physically touching another person?
Yes
No
If yes, please explain:
Does the Applicant perform background checks on hired independent contractors?
Yes
No
Is there a new employee and volunteer orientation that includes training in abuse
awareness?
Yes
No
Does the Applicant verify employment related references?
Yes
No
Does the Applicant conduct personal interviews?
Yes
No
Does the Applicant have written procedures dealing with sexual abuse?
Yes
No
If yes, please attach a copy.
Does the Applicant have a plan of supervision that monitors staff in day-to-day relationships
with students, both on and off premises such as class trips?
Yes
No
Does the Applicant have a Sexual Abuse Awareness Program for students?
Yes
No
Does the Applicant have a specific training for the faculty on identifying and reporting
incidents of sexual abuse and molestation?
Yes
No
Has the Applicant’s organization ever had an incident which resulted in an allegation of
sexual abuse? If yes, please describe the incident:
Yes
No
Was a claim made against the organization?
Yes
No
If yes, was the case settled?
Yes
No
If yes, was the case taken to trial?
Yes
No
How much money was paid in damages to the victim: $
Does the Applicant’s current insurance program provide abuse and molestation coverage?
Yes
No
If yes:
Occurrence
Claims Made
If Claims Made – Retroactive Date:
Limit: $
Carrier:
Student Housing Supplemental
Page 4 of 7
© 2019 Philadelphia Consolidated Holding Corp.
07/2019
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SECTION V - AUTOMOBILE
1.
Does the Applicant provide shuttle service for students?
Yes
No
If yes:
a.
Does the Applicant use an independent contractor to provide the shuttle service?
Yes
No
b.
Are Certificates of Insurance required from the contractor?
Yes
No
If yes, attach Certificate of Insurance.
c.
Is the Applicant an additional insured on the contractor’s policy?
Yes
No
2.
Approximately how many vehicles are hired or borrowed annually?
Total cost of hire: $
3.
Yes
No
For those employees who use their own vehicles for business, either full-time or
occasionally, does the Applicant require the employee to carry primary insurance?
If yes, what is the minimum limit the Applicant is requiring them to carry? $
4.
Does the Applicant have a full-time fleet manager?
Yes
No
If yes, please advise:
Number of years in current position:
Total number of years’ experience:
If no, who is responsible for fleet safety and maintenance?
5.
Does the Applicant have a routine maintenance program for all vehicles?
Yes
No
6.
Are maintenance records kept for each vehicle?
Yes
No
7.
Does the Applicant’s organization utilize GPS fleet telematics devices?
Yes
No
If yes, please check off the fleet telematics being utilized:
Plug In
Hard Wired
Mobile Phone
Other:
8.
What percentage of the Applicant’s fleet is provided with these fleet telematics devices? %
9.
Does the Applicant obtain Motor Vehicle Reports on ALL employees?
Yes
No
If yes, when?
At time of hire
Annually
Randomly (based on accidents or suspicions)
10.
Does the Applicant have a formal driving policy in place with MVR standards?
Yes
No
a.
Is driving policy communicated in writing to all employees?
Yes
No
Does the policy prohibit the use of cellphones/electronic messaging while driving?
Yes
No
b.
Is a signed acknowledgement form kept on file?
Yes
No
If yes, please attach a copy of signed acknowledgement.
c.
Does the Applicant have written guidelines defining an acceptable Motor Vehicle
Record?
Yes
No
If yes, attach copy of guidelines.
11.
What action is taken if an “unacceptable” driver is identifiable?
12.
Does the Applicant perform accident investigations for each automobile accident?
Yes
No
13.
Does the Applicant allow any newly hired drivers to operate vehicles without going through
a company-specific documented driving training?
Yes
No
14.
Describe any ongoing training provided to drivers:
15.
Describe security regarding vehicle storage:
Locked Garage
Fenced Lot
Lighting
Security Cameras
Security Personnel
Vehicle Locked When Unattended
Other:
Student Housing Supplemental
Page 5 of 7
© 2019 Philadelphia Consolidated Holding Corp.
07/2019
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WINTER WEATHER FREEZE-UP PROTECTION
1. Fire Protection and Testing
a. Is the building provided with an Automatic Fire Sprinkler System (AS)? Yes No N/A
i. If yes, approximately what percentage (%) of the building is sprinklered? %
ii. If yes, what type of sprinkler system is installed? Wet-Pipe Dry-Pipe Both
iii. If yes, when possible, is the sprinkler piping primarily run within conditioned
areas designed to ensure the temperature remains above the 45°F minimum
Yes No N/A
iv. If yes, is the testing & inspection by qualified sprinkler contractor completed
within past 12 months & includes a formal winterization revie
w?
Yes
No
N/A
v. If yes, are the alarms tied to a 24 hour UL listed monitoring company?
Yes
No
N/A
2. Emergency Water Response (domestic and AS water lines)
a. Are water shutoff valves (domestic and AS water lines) marked and readily
accessible?
Yes
No
N/A
b. Are water shutoff valves exercised (closed and reopened) at least annually?
Yes
No
N/A
c. Is the staff qualified to respond and shut off the water main during normal business
hours and off hours?
Yes
No
N/A
3. Automatic Water Shutoff Devices
a. For domestic water lines, is there a water flow detection, notification and automatic
shutoff?
Yes
No
N/A
4. Unused/Vacant Spaces
a. Does Applicant have a formal process to turn off and drain domestic water lines for
these spaces?
Yes
No
N/A
5. Unheated Areas (attics, crawl spaces, exterior wall joists)
a. Are all domestic water lines located in areas heated to at least 45°F?
Yes
No
N/A
i. If no, please describe freeze prevention measures (e.g. temperature monitoring,
heat trace, full insulation):
This section must be completed by all risks that have a location in one of the following states: AR, CT, DC, DE,
GA, IL, IN, KY, ME, MD, MA, MI, MO, NH, NY, NJ, NC, OH, PA, RI, SC, TN, TX, VT, VA, WV, WI
temperature?
1. If no, please describe freeze prevention measures (
e.g. temperature
monitoring,
heat trace, full insulation on piping or roof):
6.
General Comments:
Student Housing Supplemental
Page 6 of 7
© 2019 Philadelphia Consolidated Holding Corp.
07/2019
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FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge
and belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this
Application) are true and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in
this Application changes prior to the effective date of the policy, the Applicant will notify the Company of such changes and the
Company may modify or withdraw the quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF
ISSUED, MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING
WHICH IT IS IN EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION
FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THAT
PERSON TO CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT
INSURANCE ACT WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO
EXCEED FIVE THOUSAND DOLLARS ($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN
AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, PA, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION
IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION
TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY
INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE
COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR
CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A
SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE
WITHIN THE DEPARTMENT OF REGULATORY AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY
INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS
GUILTY OF A FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES
TO BE PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED
INSURER, BROKER OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR
TELEPHONIC COMMUNICATION OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE
RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT
PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN
MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING,
INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER
PERSONS FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR
MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE
IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN PENNSYLVANIA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER
PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR
CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT
INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER
PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR
CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT
INSURANCE ACT, WHICH IS A CRIME AND SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE
STATE VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR
EXECUTIVE DIRECTOR)
_____________________________________________________________
SIGNATURE DATE
SECTION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
Student Housing Supplemental
Page 7 of 7
© 2019 Philadelphia Consolidated Holding Corp.
07/2019
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