Fillable Condominium/Homeowners Association Application (Risk Placement Services, Inc.)

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Condominium/Homeowners Association Application (Risk Placement Services, Inc.)

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The Condominium/Homeowners Association Application (Risk Placement Services, Inc.) form is 5 pages long and contains:

  • 2 signatures
  • 65 check-boxes
  • 243 other fields

Country of origin: US
File type: PDF

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S314 (04/05) Page 1 of 5
Agent Name: Contact:
Agent Address: Phone #
Condominium/Homeowners Association Application
All questions must be answered in full. Application must be signed and dated by the applicant.
Applicant’s Name
Agent
Applicant’s Phone Number
Web Address
Applicant Mailing Address
Inspection Contact
Proposed Policy Period to Phone Number for Inspection Contact
Applicant is Individual Partnership Corporation Joint Venture Other
Location #1
Location #2
Location #3
UNDERWRITING INFORMATION
1. Number of Single Family Units
Condominium / Townhouse Units
2. % Owner Occupied
% Tenant Occupied .
3. Number of stories (over 7 stories, submit)
Construction
4. Age of buildings
Total Square Footage
5. Does Developer retain any interest in the Association? .............................................................................. Yes No
If yes, submit.
6. Number of miles of streets the Association maintains
If over 5 miles, submit.
7. Year of latest update:
Roof Plumbing Wiring
If aluminum wiring verify all outlets are pigtailed.
8. Surrounding area:
Improving Stable Declining
9. Security:
Does the Association employ security guards? ............................................................................................... Yes No
If yes, are the guards independent contractors or employees of the association?
If guards are independent contractors a certificate of insurance must be obtained from the service.
If guards are employees of the association rate separately; Basis of premium is total payroll. Submit for armed guards.
10. Does the association provide drinking water to members? ............................................................................. Yes No
If yes, attach a completed Rural Water Company Supplemental Application, S370s.
S314 (04/05) Page 2 of 5
RECREATIONAL FACILITIES
Complete for swimming pools or lakes:
POOLS
N
umber of Pools
Is pool fenced from all units?............................................................................................... Yes No
If no, submit.
Are there self-locking gates? .............................................................................................. Yes No
Does the pool have depth markers? ................................................................................... Yes No
Are rules posted?................................................................................................................
Yes No
Is there lifesaving equipment in place? ............................................................................... Yes No
Is there a lifeguard? ............................................................................................................ Yes No
Is there a diving board?....................................................................................................... Yes No
Is there a slide?................................................................................................................... Yes No
If yes, what is the height?
(If over 1 meter, submit.)
Does association sponsor a swim or dive team? ............................................................... Yes No
If yes, submit.
PONDS/LAKES
Number of lakes/ponds? Number of acres: Max. depth of water:
Is the lake fenced? ............................................................................................................. Yes No
If no, are rules posted concerning use at your own risk? .................................................. Yes No
If no, submit.
Is swimming allowed? ........................................................................................................ Yes No
If yes, are signs posted swim at your own risk? ................................................................. Yes No
If no, submit.
Any diving platforms? ......................................................................................................... Yes No
If yes, submit.
Any docks or piers?............................................................................................................. Yes No
If yes, signs must be posted no jumping or diving allowed.
Any watercraft rental? ......................................................................................................... Yes No
If yes, describe number and type.
A rental agreement with a hold harmless agreement must be used.
Any water skiing or jet ski allowed on lake? ........................................................................... Yes No
If yes, submit.
ADDITIONAL EXPOSURES
1. Describe playground equipment (e.g. fenced condition, height, etc.)
2. Complete the number of the following:
Volleyball Courts Tennis Courts Basketball Courts Baseball Fields
Parks (acres) Clubhouse (sq. ft.) Biking Trails (miles) Jogging Trails (miles)
Exercise Facilities
S314 (04/05) Page 3 of 5
COMMERCIAL PROPERTY
(Please provide complete information for each insured location. Attach separate sheet, if necessary.)
BUILDING INFORMATION
LOC. 1 LOC. 2 LOC. 3
CONSTRUCTION:
YEAR BUILT:
# OF STORIES:
TOTAL SQ. FOOTAGE:
PROTECTION CLASS:
ALARM
Central Station
Local
None
Central Station
Local
None
Central Station
Local
None
YEAR OF LATEST UPDATE
Roof
Plumbing
Wiring
Roof
Plumbing
Wiring
Roof
Plumbing
Wiring
LIMITS & COVERAGE – PROPERTY
COVERAGE COINSURANCE %
DEDUCTIBLE
CAUSES
OF LOSS
VALUATION LOC 1 LOC 2 LOC 3
BUILDING
% $ $ $ $
BPP
% $ $ $ $
BUSINESS INCOME
%
or
Monthly Limit
$
$
Basic
Broad
Special
A.C.V.
R.C.
Market
Value (Submit)
$ $ $
SIGNS (DESCRIBE)
$ $ $
TOTAL LIMITS
$ $ $
ADJACENT EXPOSURES
RIGHT LEFT FRONT REAR
LOC. 1
LOC. 2
LOC. 3
CONTRIBUTING INSURANCE
NAME & ADDRESS OF COMPANY % PARTICIPATION LIMITS
S314 (04/05) Page 4 of 5
LIMITS – GENERAL LIABILITY (PER OCCURRENCE)
GENERAL AGGREGATE (OTHER THAN PRODUCTS/COMPLETED OPERATIONS) $
PRODUCTS & COMPLETED OPERATIONS AGGREGATE $
PERSONAL & ADVERTISING INJURY (ANY ONE PERSON OR ORGANIZATION) $
EACH OCCURRENCE $
DAMAGE TO PREMISES RENTED TO YOU (ANY ONE PREMISES) $
MEDICAL EXPENSE (ANY ONE PERSON) $
CERTIFICATE RECIPIENTS / ADDITIONAL INTERESTS
NAME AND ADDRESS
RELATIONSHIP
TO APPLICANT
ADDITIONAL
INSURED
CERTIFICATE
PRIOR CARRIER HISTORY & LOSS INFORMATION
PRIOR CARRIERS (LAST THREE YEARS):
YEAR CARRIER POLICY NUMBER LIMITS PREMIUM
LOSS HISTORY (LAST FIVE YEARS)
DATE OF LOSS TYPE OF LOSS DESCRIPTION OF LOSS AMOUNT PAID RESERVE
S314 (04/05) Page 5 of 5
Has the applicant been cancelled or non-renewed in the last three years? ............................................................
Yes No
If yes, Explain.
This application shall not be binding unless and until confirmation by the Company or its duly appointed representatives has
been given, and that a policy shall be issued and a payment shall be made, and then only as of the commencement date of
said policy and in accordance with all terms thereof. The said applicant hereby covenants and agrees that the foregoing
statements and answers are a full and true statement of all the facts and circumstances with regard to the risk to be insured,
and the same are hereby made the basis and conditions of the insurance and a warranty on the part of the Insured.
Producer’s Signature Date Applicant's Signature Date
IMPORTANT NOTICE
As part of our underwriting procedure, 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.
FRAUD STATEMENT
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.
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CondominiumHomeowners Association Application (Risk Placement Services, Inc.)

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Completed 30 July 2020

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