Fillable Condominium or Homeowners Association General Liability Application (RT Specialty)

Fill Online, Printable, Fillable, Blank Condominium or Homeowners Association General Liability Application (RT Specialty) Form

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

Condominium or Homeowners Association General Liability Application (RT Specialty)

On average this form takes 76 minutes to complete

The Condominium or Homeowners Association General Liability Application (RT Specialty) form is 6 pages long and contains:

  • 2 signatures
  • 10 check-boxes
  • 291 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your RT Specialty forms online.

BROWSE RT SPECIALTY 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
 
Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675 • Fax (480) 483-6752
www.scottsdaleins.com
Condominium or Homeowners Association General Liability Application
Applicant’s Name:
Mailing Address:
Location Address:
Web site Address:
Agency Name:
Agent:
Address:
E-mail:
Phone:
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”
Applicant is: Individual Corporation Partnership Joint Venture
Limited Liability Company Other (Specify):
Limits Of Liability And Deductible Requested:
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) $
Limited Sports Participants Liability $
Other Coverages, Restrictions and/or Endorsements:
$
Deductible $
1. Years in business:
2. Is there any development and/or construction operations contemplated or in progress? ............... Yes No
If yes, explain:
GLS-APP-10s (5-12) Page 1 of 6
Submit Here
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. Number of stories:
Sprinklered? ................................................................................................................................................. Yes No
Fire resistive? .............................................................................................................................................. Yes No
10. Total number of employees:
11. Does applicant lease employees? ........................................................................................................... Yes No
12. 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:
13. Any prior losses due to mold? ................................................................................................................. Yes No
If yes, has mold been completely remediated? ........................................................................................... Yes No
14. Is this a master association which provides group common areas for individual associations?.... Yes No
15. Is this a community development that includes residential with commercial and/or institutional
members? ...................................................................................................................................................
Yes No
16. Does the association have an airport or airstrip? .................................................................................. Yes No
17. Any waterworks/sewage treatment/disposal facilities? ........................................................................ Yes No
Describe in detail:
If yes, is it maintained and operated by insured? ........................................................................................ Yes No
18. Any garbage dumps or landfills? ............................................................................................................. Yes No
19. Is the association responsible for maintenance of the roads? ............................................................ Yes No
If so, how many miles of road?
GLS-APP-10s (5-12) Page 2 of 6
20. Any stables? .............................................................................................................................................. Yes No
If yes, advise payroll:
Riding arenas? ........................................................................................................................................... Yes No
Jumps? ....................................................................................................................................................... Yes No
Saddle animals for hire? ........................................................................................................................... Yes No
21. Number of:
Baseball fields
**Lakes
acres
Basketball courts
Parks
acres
Bathing beaches
Playgrounds
Bicycle Trails
miles
Racquetball courts
Boat docks/slips
Restaurants/Lounges
Boat ramps
Saunas
Boat rentals
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
Ice skating
* If applicable, complete Dam Questionnaire GLS-113
** Is swimming allowed in the lakes? ........... Yes No
22. 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
Slides over 10 ft. 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
23. 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 subconractor? ................................................................... Yes No
d. Is applicant included as an additional insured on subcontractor’s policy? ........................................... Yes No
24. Does applicant have Workers Compensation coverage in force? ....................................................... Yes No
GLS-APP-10s (5-12) Page 3 of 6
25. Any special events? .................................................................................................................................. Yes No
If yes, describe:
26. Any sponsored athletic teams? ............................................................................................................... Yes No
If yes, describe:
27. Describe any other exposures which the association is responsible for:
28. Attach any descriptive or advertising literature.
29. Additional Insured Information:
Address
Interest
30. 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:
31. During the past three years, has any company canceled, declined or refused similar insurance
to the applicant? (Not applicable in Missouri) ...........................................................................................
Yes No
If yes, explain:
32. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
33. Prior Carrier Information:
Year:
Year:
Year:
Carrier
Policy No.
Coverage
Occurrence or
Claims Made
Total Premium
34. 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 last three years.
Date of
Loss
Description of Loss
Amount
Paid
Amount
Reserved
Claim Status
(Open or Closed)
GLS-APP-10s (5-12) Page 4 of 6
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 Nebraska, Oregon and Vermont.
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
addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any in-
surer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a
felony in the third degree.
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 and willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly and 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 knowingly and with intent to defraud any insurance company 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.
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 Tennessee, Virginia and Washington): It is a crime to knowingly provide false, in-
complete or misleading information to an insurance company for the purpose of defrauding the company. Penalties in-
clude imprisonment, fines and denial of insurance benefits.
GLS-APP-10s (5-12) Page 5 of 6
NOTICE TO NEW YORK APPLICANTS (Other than automobile): 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.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: _____________________________________________________________________________ DATE:
(Must be signed by an active owner, partner or executive officer)
PRODUCER’S SIGNATURE: DATE:
NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT:
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.
GLS-APP-10s (5-12) Page 6 of 6
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

Condominium or Homeowners Association General Liability Application (RT Specialty)

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 13 December 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document