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 22 minutes to complete

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

  • 2 signatures
  • 82 check-boxes
  • 42 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‐APP029‐0815 Page1of4
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION - MOBILE HOME PARKS - 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)
Aluminum wiring
Armed security guards, off duty peace officers acceptable
LPG tank filling (tank swapping from locked cages outside of building are acceptable)
SUBMIT
Student housing exceeds 25% Actual is _____ %
Subsidized housing exceeds 25% Actual is _____%
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
C‐APP029‐0815 Page2of4
MOBILE HOME PARKS - SUPPLEMENTAL APPLICATION
EXPOSURES / OPERATIONS / CONTROLS (check all that apply)
Applicant provides hook-up service that include gas connections by insured or by employees
Lease of Mobile Home Pads:
If yes, number of pads available for lease: ______ Number of pads actually rented: _____
Rental of mobile homes owned by applicant:
Number of mobile homes available for rent: _____ Number of units actually rented: _____
All units over 20 years old have had a professional heating system inspection
All units over 10 years old have had a professional electrical inspection
Carbon monoxide detectors provided in all units
Fire extinguishers in all unit
Rented units have regular inspection and maintenance
Smoke detectors are in all units: Battery Hardwired
Rental periods may be as short as one week
Porches have railings and steps have handrails
Bar/Tavern/Lounge If yes, owned and/or operated by: Insured Third Party
Beachfront
Boat Docks / Ramps / Slips If yes, total number of all: _______
Boat Rentals by applicant Rentals that are other than row or sail boats:
Clubhouse – rented to residents only
Clubhouse – rented to non-residents
Convenience store If yes, owned and/or operated by: Insured Third Party
Fire extinguishers placed in common areas (if any) and all are currently tagged
Fitness center
Hot tub / Sauna / Steam room
Lakes (must be posted no swimming) If yes, number of total acres of water: _____
Manager lives on premises
Residents provided with contact(s) that provide 24/7 emergency services
Leases for pads or mobile homes prohibit ownership of vicious breeds
Playground(s)
Restaurant (complete Restaurant Supplemental Application)
Roads owned, controlled and/or maintained by applicant If yes, paved unpaved.
Sale (by applicant) of LP or Natural Gas
Sale (by applicant) of gasoline
Sewage Treatment Facilities that are owned and operated by the applicant
Storage tanks - Underground If yes (describe):
Storage tanks – Above ground If yes (describe):
Sauna / Steam Room
Storage units provided by application that are not inside of individual living units
C‐APP029‐0815 Page3of4
MOBILE HOME PARKS - SUPPLEMENTAL APPLICATION
EXPOSURES / OPERATIONS / CONTROLS (check all that apply) cont.
Swimming Pool(s) Number of swimming pools: _______
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
Water treatment (other than wastewater) provided via facilities that are owned and/or operated by the insured or
Insured’s employee(s)
Additional exposures not listed above (describe):
RECEIPTS
Campgrounds $
Convenience Store $
Gasoline $
Mobile Home Park $
Propane Tanks (only swap is acceptable) $
Restaurant/Snack Bar $
Other (describe): $
Other (describe): $
TOTAL of all receipts $
SUBCONTRACTORS
Uninsured subcontractors are not acceptable. Exceptions allowed in Texas subject to Company guidelines.
Describe type of work performed by subcontractors:
Risk transfer – Subcontractors:
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): __________
C‐APP029‐0815 Page4of4
MOBILE HOME PARKS - SUPPLEMENTAL APPLICATION
COVERAGE OPTIONS - LIABILITY (check if you would like a 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 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
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