Fillable Condominium Unit Owner Product Application All States (Risk Placement Services, Inc.)

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Condominium Unit Owner Product Application All States (Risk Placement Services, Inc.)

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page 1 of 3
CUOP 5/15 – USLI
CARRIER:
II. LOSS HISTORY
III. ELIGIBILITY CRITERIA QUESTIONS
1. Is a United States Liability Insurance Group company the expiring carrier? (Mount Vernon Fire Insurance Company,
United States Liability Insurance Company, or U.S. Underwriters) q Yes q No
2. Is any member of the household a federal or state political figure, professional athlete or coach,
music or television entertainer, or CEO of a Fortune 500 Company? q Yes q No
3. Has the applicant or any member of the applicant’s household been convicted of a felony within the past 5 years? q Yes q No
4. Are there any business exposures of any kind present at any location? q Yes q No
5. Will there be any construction or renovation taking place during the next 12 months? q Yes q No
If “yes,” please answer the following questions:
a. Will a licensed general contractor, other than the named insured, be contracted to
do the construction/renovation? q Yes q No
b. Will the construction or renovation include demolition? q Yes q No
6. Are there any wood burning or coal stoves, space heaters, or temporary heating devices? q Yes q No
Date Type Description Amount
Condominium Unit Owner Product Application – All States
YOU CAN OBTAIN A QUOTE BY PROVIDING THE INFORMATION IN SECTION I - INSTANT QUOTE BELOW, SUBJECT TO THE REMAINDER PROVIDED PRIOR TO BINDING.
I. INSTANT QUOTE INFORMATION
Instant Quote is only available for accounts with no losses in the past three years. If there is loss history, please complete the entire application.
Applicant’s name: _______________________________________________________________________ Entity Type: _______________
Location address: ________________________________________________________ Unit/Apt. #: ___________ q Same as mailing address
City: _________________________________________________ State: ___________________ Zip: ______________________
Protection class: _______________________________________
Occupancy: q Owner occupied unit q Unit leased to others q Vacant unit
Deductible q $500 q $1,000 q $2,500
Optional coverage for unit owners:
q Increased Loss Assesment ($1,000 included) _________________________ (up to $50,000)
q Refrigerated Property Coverage
Optional coverages for owner-occupied units only:
q Special Form Coverage for contents q Replacement Cost for contents
q Personal Property kept at another owned residence
Protection Systems (check all that apply): q Central Station Burglar q Central Station Fire q Automatic Sprinkler System
Have there been any claims or losses in the past three years regardless of type or amount? q Yes q No
Coverage A
Dwelling
Coverage C
Personal Property
Coverage D
Loss of Use
($5,000 included)
Coverage E
Personal Liability
Coverage F
Medical Payments
$5,000 (incl)
page 2 of 3
CUOP 5/15 – USLI
7. If/when the unit is unoccupied, are the utilities and temperature controls maintained at a minimum level
appropriate to maintain the unit? q Yes q No
8. Are there functioning and operational smoke detectors in all units? q Yes q No
IV. LOCATIONS RENTED TO OTHERS
1. Is the unit rented on a short term or seasonal basis? q Yes q No
2. Does the applicant re-key all locks prior to leasing to new tenants? (Not applicable if rented on a seasonal basis.) q Yes q No
3. Are any locations group homes, boarding, rooming, or corporate housing facilities? q Yes q No
4. Are there any student residents at any location? (Not applicable in DC) q Yes q No
5. Are there any subsidized residents at any location? (Not applicable in CA, CT, DC, ME, MA, NJ, OR,
UT, VT, and WI) q Yes q No
V. ADDITIONAL INSURED INFORMATION
1. Is an additional insured endorsement required for this risk? q Yes q No
Landlord / Additional Insured
Name: _________________________________________________________________________________________________________
Address: _______________________________________________________________________________________________________
Interest in unit: __________________________________________________________________________________________________
IV. ADDITIONAL APPLICANT INFORMATION
Applicant’s mailing address: ______________________________________________ (if different than the location address above)
City: _______________________________________________ State: ___________________ Zip: _____________________
E-mail address of primary contact: ________________________________________ Phone: _________________________________
FRAUD STATEMENTS
Alabama, Arkansas, District of Columbia, New Mexico, Rhode Island and West Virginia: 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.
Colorado Fraud Statement: 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.
Florida Fraud Statement: 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 of the third degree.
Kansas Fraud Statement: 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 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 commits a fraudulent insurance act.
Maine Fraud Statement: 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
Maryland Fraud Statement: 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.
New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and
civil penalties.
New York Fraud Statement: 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.
Oklahoma Fraud Statement: WARNING: 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 information is guilty of a felony.
Oregon Fraud Statement: Notice to Oregon applicants: Any person who, with intent to defraud or knowing that he is facilitation a fraud against an insurer,
submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
Kentucky, Pennsylvania AND Ohio Fraud Statement: 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.
Tennessee, Virginia and Washington Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company
for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Fraud Statement (All Other States): 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.
page 3 of 3
CUOP 5/15 – USLI
STATE NOTICES
Arizona Notice: Misrepresentations, omissions, concealment of facts and incorrect statements shall prevent recovery under the policy only if the
misrepresentations, omissions, concealment of facts or incorrect statements are; fraudulent or material either to the acceptance of the risk, or to the hazard
assumed by the insurer or the insurer in good faith would either not have issued the policy, or would not have issued a policy in as large an amount, or would not
have provided coverage with respect to the hazard resulting in the loss, if the true facts had been made known to the insurer as required either by the application
for the policy or otherwise.
Florida Surplus Lines Notice: (Applies only if policy is non-admitted) You are agreeing to place coverage in the surplus lines market. Superior coverage may be
available in the admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act with
respect to any right of recovery for the obligation of an insolvent unlicensed insurer.
Florida and Illinois Punitive Damage Notice: I understand that there is no coverage for punitive damages assessed directly against an insured under Florida
and Illinois law. However, I also understand that punitive damages that are not assessed directly against an insured, also known as “vicariously assessed
punitive damages”, are insurable under Florida and Illinois law. Therefore, if any Policy is issued to the Applicant as a result of this Application and such Policy
provides coverage for punitive damages, I understand and acknowledge that the coverage for Claims brought in the State of Florida and Illinois is limited to
“vicariously assessed punitive damages” and that there is no coverage for directly assessed punitive damages.
Maine Notice: The insurer is not permitted to withdraw any binder once issued, but a prospective notice of cancellation may be sent and coverage denied for
fraud or material misrepresentation in obtaining coverage. A policy may not be unilaterally rescinded or voided.
Minnesota Notice: Authorization or agreement to bind the insurance may be withdrawn or modified only based on changes to the information contained in this
application prior to the effective date of the insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10
days’ notice given to the insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for
nonpayment of premium.
Ohio Representation Statement: By acceptance of this policy, the Insured agrees the statements in the application (new or renewal) submitted to the company
are true and correct. It is understood and agreed that, to the extent permitted by law, the Company reserves the right to rescind this policy, or any coverage
provided herein, for material misrepresentations made by the Insured. It is understood and agreed that the statements made in the insurance applications
are incorporated into, and shall form part of, this policy. THE INSURED UNDERSTANDS AND AGREES THAT ANY MATERIAL MISREPRESENTATION
OR OMISSION ON THIS APPLICATION WILL ACT TO RENDER ANY CONTRACT OF INSURANCE NULL AND WITHOUT EFFECT OR PROVIDE THE
COMPANY THE RIGHT TO RESCIND IT.
Utah Punitive Damages Notice: I understand that Punitive Damages are not insurable in the state of Utah. There will be no coverage afforded for Punitive
Damages for any Claim brought in the State of Utah. Any coverage for Punitive Damages will only apply if a Claim is filed in a state which allows punitive or
exemplary damages to be insurable. This may apply if a Claim is brought in another state by a subsidiary or additional location(s) of the Named Insured, outside
the state of Utah, for which coverage is sought under the same policy.
If your state requires that we have information regarding your Authorized Retail Agent or Broker, please provide below.
Retail agency name:____________________________________________________ License #:
________________________________________________
Agent’s signature:______________________________________________________ Main agency phone number: _________________________________
(Required in New Hampshire)
Agency mailing address: __________________________________________________________________________________________________________
City: _______________________________________________________________________ State:__________________ Zip: ______________________
The signer of this application acknowledges and understands that the information provided in this Application is material to the Insurer’s decision to provide the
requested insurance and is relied on by the Insurer in providing such insurance. The signer of this application represents that the information provided in this
Application is true and correct in all matters. The signer of this Application further represents that any changes in matters inquired about in this Application occurring
prior to the effective date of coverage, which render the information provided herein untrue, incorrect or inaccurate in any way will be reported to the Insurer
immediately in writing. The Insurer reserves the right to modify or withdraw any quote or binder issued if such changes are material to the insurability or premium
charged, based on the Insurer’s underwriting guides. The Insurer is hereby authorized, but not required, to make any investigation and inquiry in connection with
the information, statements and disclosures provided in this Application. The decision of the Insurer not to make or to limit any investigation or inquiry shall not be
deemed a waiver of any rights by the Insurer and shall not estop the Insurer from relying on any statement in this Application in the event the Policy is issued. It is
agreed that this Application shall be the basis of the contract should a policy be issued and it will be attached and become a part of the Policy.
Applicant’s signature:
______________________________________________________________________ Title: ___________________________________
President, Chairperson of the Board, Managing Member, or Executive Director
Date:_____________________________________________________
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Condominium Unit Owner Product Application All States (Risk Placement Services, Inc.)

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Completed 30 July 2020

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