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CONDOMINIUM AND HOMEOWNERS ASSOCIATION GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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GL-APP-10s (7-18) Page 1 of 7
CONDOMINIUM AND HOMEOWNERS ASSOCIATION GENERAL LIABILITY APPLICATION
Applicant’s Name:
Mailing Address:
Location Address:
Agency Name:
Agent No.:
Address:
E-mail:
Phone No.:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
Applicant is: Individual Corporation Partnership Joint Venture Limited Liability Company
Other (Specify):
Website Address:
E-mail Address: Phone No.:
Limits Of Liability and Deductible Requested:
General Aggregate (other than Products/Completed Operations) $
Products and Completed Operations Aggregate $
Personal and Advertising Injury (any one person or organization) $
Each Occurrence $
Damage to Premises Rented to You (any one premises) $
Medical Expense (any one person) $
Limited Sports Participants Liability $
Other Coverages, Restrictions and/or Endorsements:
$
Deductible $
GL-APP-10s (7-18) Page 2 of 7
1. Years in business: .....................................................................................................................................
2. Is there any development and/or construction operations contemplated or in progress? ............... Yes No
If yes, explain:
3. Is the builder or developer a member of the board of directors for the association? ....................... Yes No
4. How many units are in the name of or owned by the builder or developer? ......................................
5. Is association membership voluntary? ................................................................................................... Yes No
If yes: How many unit owners are association members? ........................................................................
How many non-association units are within the boundaries of the association? ...........................
6. Number of units:
Condominiums—Commercial: Condominiums—Residential: Cooperative housing:
Single family homes: Time-shares: Townhomes/Townhouses:
Other (describe):
7. How many of the units have not been sold? ..........................................................................................
8. How many units are rented to others (not owner occupied)? ..............................................................
If units are rented to others, how many units does the Association control the rental of? ..........................
How many units are rented on a daily, weekly or monthly basis? ...............................................................
9. For condominium associations, are there any seasonal, secondary or vacation units? .................. Yes No
10. Number of stories: .....................................................................................................................................
Sprinklered? ................................................................................................................................................. Yes No
Fire resistive? .............................................................................................................................................. Yes No
11. Total number of employees: ....................................................................................................................
12. Does applicant lease employees? ........................................................................................................... Yes No
13. Does applicant subcontract any operations? ........................................................................................ Yes No
If yes:
a. Description of operations subcontracted:
b. Annual cost of subcontracted work: ......................................................................................................
c. Are all subcontractors required to carry General Liability and Workers Compensation Insurance? .... Yes No
If yes, minimum General Liability limits required:..................................................................................
d. Are certificates of insurance required from all subcontractors? ............................................................ Yes No
e. Is applicant included as an additional insured on all subcontractors’ policies? .................................... Yes No
f. Do written contracts contain hold-harmless agreements in favor of the applicant? ............................. Yes No
If no, explain when not required:
14. Any prior losses due to mold? ................................................................................................................. Yes No
If yes, has mold been completely remediated? ........................................................................................... Yes No
15. Is this a master association, which provides group common areas for individual associations? .. Yes No
GL-APP-10s (7-18) Page 3 of 7
16. Is this a community development that includes residential with commercial and/or institutional
members? ................................................................................................................................................... Yes No
17. Does the association have an airport or airstrip? .................................................................................. Yes No
18. Any waterworks/sewage treatment/disposal facilities? ........................................................................ Yes No
Describe in detail:
If yes, is it maintained and operated by applicant? ..................................................................................... Yes No
19. Any garbage dumps or landfills? ............................................................................................................. Yes No
20. Is the association responsible for maintenance of the roads? ............................................................ Yes No
If yes, how many miles of road? ..................................................................................................................
21. Any stables? .............................................................................................................................................. Yes No
If yes, advise payroll:
Riding arenas? ............................................................................................................................................. Yes No
Jumps? ........................................................................................................................................................ Yes No
Saddle animals for hire? .............................................................................................................................. Yes No
22. Number of:
Baseball Fields Ice Skating
Basketball Courts Lakes** acres
Bathing Beaches Parks acres
Bicycle Trails miles Playgrounds
Boat Docks/Slips Racquetball Courts
Boat Ramps Restaurants/Lounges
Boat Rentals (paddle,
canoe and rowboats)
Saunas
Shooting Ranges
Clubhouses sq ft. Shuffleboard Courts
Convenience Stores Spas/Hot Tubs
Dams* Streets/Roads miles
Diving Rafts Tennis Courts
Horse Trails miles Volleyball Courts
* If applicable, complete dam questionnaire GLS-113.
** Is swimming allowed in the lakes? ........................................................................................................ Yes No
If yes to Boat Rentals, are Coast Guard approved flotation devices provided for all passengers? ............ Yes No
23. Number of swimming pools and/or wading pools? ...............................................................................
Number of diving boards, diving platforms and/or pool slides: ....................................................................
Diving boards or platforms over one meter in height? ................................................................................. Yes No
Equipped with self-closing and self-latching gates/doors? .......................................................................... Yes No
Life-safety equipment available at poolside? .............................................................................................. Yes No
Lifeguards provided? ................................................................................................................................... Yes No
Pools completely surrounded by building walls or fence? ........................................................................... Yes No
GL-APP-10s (7-18) Page 4 of 7
Slides over ten (10) feet in height? .............................................................................................................. Yes No
Warning signs and rules posted? ................................................................................................................ Yes No
Are all swimming pools, wading pools, hot tubs and spas in compliance with the federal Virginia Grae-
me Baker Pool and Spa Safety Act? ........................................................................................................... Yes No
24. Any security guards on premises? .......................................................................................................... Yes No
If yes, how many? ........................................................................................................................................
a. Does association directly employ security guards? .............................................................................. Yes No
If yes: Number of unarmed guards: Number of armed guards:
b. Does outside security guard service provide guards? .......................................................................... Yes No
If yes: Number of unarmed guards: Number of armed guards:
c. Are certificates of insurance required from subcontractor? .................................................................. Yes No
d. Is applicant included as an additional insured on subcontractor’s policy? ........................................... Yes No
25. Does applicant have Workers Compensation coverage in force? ....................................................... Yes No
26. Any special events? .................................................................................................................................. Yes No
If yes, describe:
27. Any sponsored athletic teams? ............................................................................................................... Yes No
If yes, describe:
28.
Describe any other exposures which the association is responsible for:
29. Attach any descriptive or advertising literature.
30. Additional Insured Information:
Name Address Interest
31. Does risk engage in the generation of power, other than emergency back-up power, for their
own use or sale to power companies?.................................................................................................... Yes No
If yes, describe:
32. During the past three years, has any company ever canceled, nonrenewed, declined or refused
similar insurance to the applicant? (Not applicable in Missouri) ............................................................ Yes No
If yes, explain:
33. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
GL-APP-10s (7-18) Page 5 of 7
34. Prior Carrier Information:
Year: Year: Year:
Carrier
Policy No.
Coverage
Occurrence or Claims Made
Total Premium $ $ $
35. Loss History:
Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give
rise to claims for the prior three years. ............................................... Check if no losses in the last three years.
Date of
Loss
Description of Loss
Amount
Paid
Amount
Reserved
Claim Status
(Open or
Closed)
$ $
$ $
$ $
$ $
$ $
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
FRAUD WARNING: 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. (Not applicable in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY,
OH, OK, OR, RI, TN, VA, VT or WA.)
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation 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 policy holder or claimant for
the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an
insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addi-
tion, an insurer may deny insurance benefits if false information materially related to a claim was provided by the appli-
cant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insur-
er files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a fel-
ony of the third degree.
GL-APP-10s (7-18) Page 6 of 7
NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be pre-
sented 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 state-
ment 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 con-
ceals, 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.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be sub-
ject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: 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.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against
an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading infor-
mation is guilty of a felony.
NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents
a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties un-
der state law.
FRAUD WARNING (APPLICABLE IN 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. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
NEW YORK OTHER THAN AUTOMOBILE FRAUD WARNING: 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 also be subject to a civil penalty not to exceed five thousand dollars
and the stated value of the claim for each such violation.
GL-APP-10s (7-18) Page 7 of 7
The undersigned hereby authorizes the release of claim information from any prior insurer to the Company.
NAME OF ENTITY:
BY:
(Must be signed by Chairman of the Board or President)
TITLE: DATE:
PRODUCER’S SIGNATURE: DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IOWA LICENSED AGENT:
(Applicable in Iowa Only)
Signing this form does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued. Application must be currently signed
and dated to be considered for quotation.
NOTE: A copy of the association’s two latest statements of conditions and a copy of the bylaws must accompany this pro-
posal. No change in bylaws.
IMPORTANT NOTICE
As part of our underwriting procedures, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional
information as to the nature and scope of the report, if one is made, will be provided.
Agent Email: Preferred Method of Correspondence Email Fax Mail
Applicant Email: Preferred Method of Correspondence Email Fax Mail
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CONDOMINIUM AND HOMEOWNERS ASSOCIATION GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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