Fillable COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

Fill Online, Printable, Fillable, Blank COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers) Form

Use Fill to complete blank online STRICKLAND INSURANCE BROKERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

On average this form takes 18 minutes to complete

The COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers) form is 4 pages long and contains:

  • 2 signatures
  • 69 check-boxes
  • 31 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Strickland Insurance Brokers forms online.

BROWSE STRICKLAND INSURANCE BROKERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
C‐APP001‐0815 Page1of4
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION – APARTMENTS and DWELLINGS – SUPPLEMENTAL APPLICATION
ACORD Application also required - Check all applicable checkboxes below
General Agent:
Date:
Insured:
Insured Mailing Address:
Insured’s Web Address:
Insured Contact Name:
Phone Number:
PROHIBITED (check all that apply to your operations)
Adult foster care
Aluminum wiring, knob & tube or pigtail wiring, fuses rather than circuit breakers as well as Federal Pacific Stab-
Lock electrical control panels
Armed security guards, off duty peace officers acceptable
Assisted living
Condo conversions if original structure was not habitational use to begin with
Halfway houses
Heights of buildings are over 4 stories and not at least MNC construction, and 100% Sprinklered
Homeless shelters
Rehab centers
Structural renovations
SUBMIT (check if applicable)
Occupancy rate is under 75% annually. If under 75% what is actual occupancy? __________
Single Family Dwellings (SFD’s) If total exceeds 10 submit.
Student housing exceeds 25% Number of student housing units __________
Subsidized housing exceeds 25% Number of subsidized housing units __________
SEPARATELY CLASSIFY, RATE AND UNDERWRITE
Exposures include Time Shares. Separately classify, rate and underwrite Time Share exposures using either
class code 60012 – Apt Buildings or Hotels – Time-Sharing – 4 Stories or More, or class code 60013 – Apt.
Buildings or Hotels – 4 Stories or More
C‐APP001‐0815 Page2of4
APARTMENTS and DWELLINGS - SUPPLEMENTAL APPLICATION
YEARS IN BUSINESS / EXPERIENCE
_____ Years in business as the ‘Named Insured’ indicated on this application
_____ Years’ experience in the operations indicated on this application - Attach resumes if available
Has applicant had an insurance policy cancelled or non-renewed in past 3 years? If yes, explain.
(Missouri Applicants - Do not answer this question)
Applicant in receivership
Bankruptcy (Chapter 7, 11 or 13) has been filed in past 5 years
CONTRACTS
Written contracts are always used with third parties. If not, explain:
LOSS HISTORY / EVICTIONS / VIOLATIONS
Three years of loss history information on ACORD application or attached to this application
Eviction(s) in past three years If yes, how many? __________
Violations of any city, county or state housing codes in past three years
EXPOSURES / OPERATIONS / CONTROLS
_______ Average monthly rent
_______ Number of single family dwellings
_______ Number of individual apartment units
_______ Number of mobile home spaces
_______ Number of time-share units (Complete Hotel-Motel-Time Share Supplemental Application)
Elevators (if present) are properly inspected and have all code required safety features
Fire extinguishers adequately placed in common areas and all are currently tagged
Manager lives on premises
Residents provided with contact(s) that provide 24/7 emergency services
Carbon monoxide detectors are in all living units
Smoke detectors are in all living units: Battery operated Hardwired
FACILITIES (check if applicable)
Bar/Tavern/Lounge
Beachfront
Boat Docks / Ramps / Slips If yes, total number of all: __________
Clubhouse – rented to residents only
Clubhouse – rented to non-residents
Convenience store
Fitness center
Hot tub
Lakes (must be posted no swimming) If yes, total acreage of all lakes: __________
Playground
Restaurant (complete Restaurant Supplemental Application)
Sauna / Steam Room
C‐APP001‐0815 Page3of4
APARTMENTS and DWELLINGS - SUPPLEMENTAL APPLICATION
FACILITIES (check if applicable) (continued)
Swimming Pool(s) (check if applicable)
Number of swimming pools: __________
Meets Federal swimming pool/spa drain cover standards found in the Virginia Graeme Baker Pool
and Spa Safety Act
Depths marked, Life safety equipment placed in pool area, Rules posted
Competitions Diving Teams Swimming Instruction
Fenced completely with self-latching gate(s), if pool is outdoors
Life guards CPR trained Subcontracted out
Slides or diving boards Maximum height: __________ feet
SUBCONTRACTORS
Uninsured subcontractors are not acceptable. Exceptions allowed in Texas subject to Company guidelines.
Describe type of work performed by subcontractors:
Risk Transfer – Subcontractors (check if applicable):
Additional Insured – Status granted to you on the subcontractor’s policy
Certificates of Insurance - Always obtained from a subcontractor prior to any work being done for you
Limits of Liability - Subcontractors are required to carry limits equal or above your own
EMPLOYEES
Total Number of Employees (include leased employees): __________
Work performed by employees that is not
related to leasing activities or premises maintenance:
COVERAGE OPTIONS - LIABILITY (check if you would like an optional quote on any of the following)
Employee Benefit Liability – U058
Employment Practices Liability Insurance – U817 (Not available in AR, LA, MT, NM, NY, VT)
High Limits General Liability
Identity Recovery – i.e. Identity Theft – U651
Medical Expense Limit of $10,000 rather than $5,000
Stop Gap Liability – U066
COVERAGE OPTIONS - PROPERTY (check if you would like a optional quote on any of the following)
Building Ordinance or Law (Increased Cost of Construction) – U750
Equipment Breakdown – U522 and U523
Property Coverage Enhancement:
Bronze – U777C, Silver – U777B or Gold-U777A
Signs (Outdoor) 0 Co1449
Water Back Up and Sump Overflow – U548
C‐APP001‐0815 Page4of4
APARTMENTS and DWELLINGS – SUPPLEMENTAL APPLICATION
GENERAL FRAUD STATEMENT (Not applicable in all states.)
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, may be committing a fraudulent insurance act, and may be subject to
a civil penalty or fine.
The undersigned is an authorized representative of the applicant and certifies that reasonable inquiry has been made to
questions on this application. He/She certifies:
The answers are true, correct and complete to the best of his/her knowledge.
They agree to the Privacy and Fraud provisions found in the ACORD-125 (Commercial Insurance Application)
and understand those provisions also apply to this supplemental application.
SIGN AND DATE
PRODUCER’S SIGNATURE DATE
APPLICANT’S PRINTED NAME DATE
APPLICANT’S SIGNATURE DATE
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 17 July 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document