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HABITATIONAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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GL-APP-16s (7-18) Page 1 of 8
HABITATIONAL 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.:
Inspection Contact: Phone No.:
E-mail Address:
Is applicant a Real Estate or Property Management company? ................................................................. Yes 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 premise) $
Medical Expense (any one person)
$
Other Coverages, Restrictions and/or Endorsements:
$
Deductible $
GL-APP-16s (7-18) Page 2 of 8
1. How long has applicant been in business? ............................................................................................ years
2. Property Locations:
Business Name (if applicable), Street Address, City, County, State and Zip Code:
Loc. No. 1:
Loc. No. 2:
Loc. No. 3:
Loc. No. 4:
Loc. No. 5:
3. Description of Locations:
* Use alpha code listed for type of occupancy:
A—Apartment Building G—Time-share M—Student Housing
B—Garden Apartments H—Vacation Rentals N—Dwelling/One Family
C—Apartment Hotel I—Senior Housing O—Dwelling/Two Family
D—Hostel J—Assisted Living/Nursing/Convalescent P—Dwelling/Three Family
E—Boarding or Rooming House K—Fraternity/Sorority (Academic) Q—Dwelling/Four Family
F—Mobile Home L—Fraternity/Sorority (Non-academic) R—Dwelling Owner Occupied
Provide Detail Per Location Loc. No. 1 Loc. No. 2 Loc. No. 3 Loc. No. 4 Loc. No. 5
Type of occupancy*:
If mobile home, is it tied down? Yes No Yes No Yes No Yes No Yes No
Number of beds for Hostel, Board-
ing or Rooming House:
Years owned:
Year built:
No. stories:
No. units—total:
No. units per fire division:
No. buildings:
Total square feet:
Type of roof:
Manager on premises: Yes No Yes No Yes No Yes No Yes No
Fire protection:
Sprinklered:
All units
Common
area only
All units
Common
area only
All units
Common
area only
All units
Common
area only
All units
Common
area only
Fire extinguishers:
All units
Common
area only
All units
Common
area only
All units
Common
area only
All units
Common
area only
All units
Common
area only
How often checked?
Smoke detectors in each unit:
Hardwire
Battery
Hardwire
Battery
Hardwire
Battery
Hardwire
Battery
Hardwire
Battery
GL-APP-16s (7-18) Page 3 of 8
Provide Detail Per Location Loc. No. 1 Loc. No. 2 Loc. No. 3 Loc. No. 4 Loc. No. 5
Maintenance:
Janitorial operations:
Employee
Contractor
Employee
Contractor
Employee
Contractor
Employee
Contractor
Employee
Contractor
Lawn care operations:
Employee
Contractor
Employee
Contractor
Employee
Contractor
Employee
Contractor
Employee
Contractor
Upkeep of sidewalks/driveways:
Employee
Contractor
Employee
Contractor
Employee
Contractor
Employee
Contractor
Employee
Contractor
Snow/ice removal operations:
Employee
Contractor
Employee
Contractor
Employee
Contractor
Employee
Contractor
Employee
Contractor
Pool: (See Section 10.) Yes No Yes No Yes No Yes No Yes No
If occupancy is other than
habitational, please describe the
occupancy and square footage:
Percent of university or college
students as tenants:
% % % % %
Vacant?
If yes, percent of vacancy:
Yes No
%
Yes No
%
Yes No
%
Yes No
%
Yes No
%
Building(s) condemned or scheduled
for demolition:
Yes No Yes No Yes No Yes No Yes No
Conversion being done to or from
condominiums and/or townhouses:
Yes No Yes No Yes No Yes No Yes No
4. Subcontracted Work Exposures:
Provide Detail Per Location Loc. No. 1 Loc. No. 2 Loc. No. 3 Loc. No. 4 Loc. No. 5
Any new ground up constructions
anticipated within the next
twelve (12) months?
Yes No Yes No Yes No Yes No Yes No
If yes, cost of construction: $ $ $ $ $
Renovation anticipated within the
next twelve (12) months?
Yes No Yes No Yes No Yes No Yes No
If yes, cost of renovation: $ $ $ $ $
Renovation going on currently? Yes No Yes No Yes No Yes No Yes No
If yes, type of renovation:
Cost of renovation: $ $ $ $ $
General contractor used? Yes No Yes No Yes No Yes No Yes No
Subcontractors used? Yes No Yes No Yes No Yes No Yes No
If yes, certificate of insurance on file?
Yes No Yes No Yes No Yes No Yes No
Limits required: $ $ $ $ $
The applicant named as additional
Insured on their policy?
Yes No Yes No Yes No Yes No Yes No
Hold harmless agreement in favor of
the applicant in place?
Yes No Yes No Yes No Yes No Yes No
GL-APP-16s (7-18) Page 4 of 8
5. Updates:
Provide Year and
Indicate Full or Partial
Update Per Location
Loc. No. 1 Loc. No. 2 Loc. No. 3 Loc. No. 4 Loc. No. 5
Paint:
Year:
Full Update
Partial Update
Year:
Full Update
Partial Update
Year:
Full Update
Partial Update
Year:
Full Update
Partial Update
Year:
Full Update
Partial Update
Parking areas:
Year:
Full Update
Partial Update
Year:
Full Update
Partial Update
Year:
Full Update
Partial Update
Year:
Full Update
Partial Update
Year:
Full Update
Partial Update
Patio balconies/railings:
Year:
Full Update
Partial Update
Year:
Full Update
Partial Update
Year:
Full Update
Partial Update
Year:
Full Update
Partial Update
Year:
Full Update
Partial Update
Sidewalks:
Year:
Full Update
Partial Update
Year:
Full Update
Partial Update
Year:
Full Update
Partial Update
Year:
Full Update
Partial Update
Year:
Full Update
Partial Update
6. Other Exposures:
Number of: Baseball field(s) Lakes/Ponds (acres) Shuffleboard court(s)
Basketball court(s) Parks (acres) Spa/Hot tub(s)
Bathing Beaches Playground(s) Stables
Bicycle trails (miles) Racquetball court(s) Streets/Roads (miles)
Boat docks/slips Saunas Tennis court(s)
Clubhouse (sq. ft.) Shooting Ranges Volleyball court(s)
Boat rental (paddle, canoe and rowboats) .................................................................................................. Yes No
If yes: Number: ......................................................................................................................................
Are Coast Guard approved flotation devices provided for all passengers? .......................................... Yes No
Other:
Are any of these exposures available to nonresidents for a fee? ............................................................... Yes No
If yes, annual receipts: ................................................................................................................................. $
7. Swimming Pool(s): Complete if applicable.
Provide Detail Per Location Loc. No. 1 Loc. No. 2 Loc. No. 3 Loc. No. 4 Loc. No. 5
Number of swimming/wading pools:
Number of diving boards/platforms:
Height of diving boards/platforms:
Number of slides/rafts:
Height of slides:
Pool maintained by applicant or outside
contractor?
Applicant
Contractor
Applicant
Contractor
Applicant
Contractor
Applicant
Contractor
Applicant
Contractor
If outside contractor, are certificates of
insurance on file?
Yes No Yes No Yes No Yes No Yes No
Pool completely surrounded by building
walls or fence?
Yes No Yes No Yes No Yes No Yes No
Height of fence:
Equipped with self-closing and
self-latching gates/doors?
Yes No Yes No Yes No Yes No Yes No
GL-APP-16s (7-18) Page 5 of 8
Provide Detail Per Location Loc. No. 1 Loc. No. 2 Loc. No. 3 Loc. No. 4 Loc. No. 5
Lifeguards provided? Yes No Yes No Yes No Yes No Yes No
If yes, by applicant or pool management
company?
Applicant
Mgmt. Co.
Applicant
Mgmt. Co.
Applicant
Mgmt. Co.
Applicant
Mgmt. Co.
Applicant
Mgmt. Co.
If outside contractor, are certificates of
insurance on file?
Yes No Yes No Yes No Yes No Yes No
Depth of pool markings clearly visible? Yes No Yes No Yes No Yes No Yes No
Warning signs and rules posted? Yes No Yes No Yes No Yes No Yes No
Life-safety equipment available at
poolside?
Yes No Yes No Yes No Yes No Yes No
Swimming pools, wading pools, hot tubs
and spas in compliance with the federal
Virginia Graeme Baker Pool and Spa
Safety Act?
Yes No Yes No Yes No Yes No Yes No
8. Security: (not required for dwellings)
Provide Detail Per Location Loc. No. 1 Loc. No. 2 Loc. No. 3 Loc. No. 4 Loc. No. 5
How does management handle the
monitoring of master keys?
Are locks changed/re-keyed when
residents vacate the premises?
Yes No Yes No Yes No Yes No Yes No
Does management advise residents of all
criminal activity that has taken place on
the properties?
Yes No Yes No Yes No Yes No Yes No
If yes, how is this done?
Is this information provided to prospective
renters if requested?
Yes No Yes No Yes No Yes No Yes No
Is gated access provided? Yes No Yes No Yes No Yes No Yes No
If yes, hours per day:
Is entire complex gated? Yes No Yes No Yes No Yes No Yes No
Does applicant monitor any alarms in resi-
dent units?
Yes No Yes No Yes No Yes No Yes No
Are premises patrolled? ........................................................................................................................... Yes No
If yes, please answer the following questions:
Provide Detail Per Location Loc. No. 1 Loc. No. 2 Loc. No. 3 Loc. No. 4 Loc. No. 5
Number of armed guards:
Number of unarmed guards:
Are guards employees of management or
independent contractor?
Mgmt.
Contractor
Mgmt.
Contractor
Mgmt.
Contractor
Mgmt.
Contractor
Mgmt.
Contractor
If independent contractor, are certificates
of insurance required?
Yes No Yes No Yes No Yes No Yes No
Is applicant named as additional insured
on their policy?
Yes No Yes No Yes No Yes No Yes No
GL-APP-16s (7-18) Page 6 of 8
Provide Detail Per Location Loc. No. 1 Loc. No. 2 Loc. No. 3 Loc. No. 4 Loc. No. 5
Security twenty-four (24) hours? Yes No Yes No Yes No Yes No Yes No
Are guards responsible for residents’ safe-
ty and/or complex/amenities?
Yes No Yes No Yes No Yes No Yes No
Do the residents’ units contain any of the following?
Provide Detail Per Location Loc. No. 1 Loc. No. 2 Loc. No. 3 Loc. No. 4 Loc. No. 5
Call buttons: Yes No Yes No Yes No Yes No Yes No
Deadbolts: Yes No Yes No Yes No Yes No Yes No
Lock pins for windows and sliding glass
doors:
Yes No Yes No Yes No Yes No Yes No
Door viewer or peephole in front doors: Yes No Yes No Yes No Yes No Yes No
Window locks/bars: Yes No Yes No Yes No Yes No Yes No
9. Any prior losses due to mold? ................................................................................................................. Yes No
If yes, has mold been completely remediated? ........................................................................................... Yes No
10. During the past three years, has any company ever canceled, non-renewed, declined or refused
similar insurance to the applicant? (Not applicable in Missouri) ............................................................ Yes No
If yes, explain:
11. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
12. 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:
13. Additional Insured Information:
Name Address Interest
14. Prior Carrier Information:
Year: Year: Year: Year: Year:
Carrier:
Policy Number:
Coverage:
Total Premium: $ $ $ $ $
GL-APP-16s (7-18) Page 7 of 8
15. 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 five years. Check if no losses in the last five
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.
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.
GL-APP-16s (7-18) Page 8 of 8
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 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.
APPLICANT’S STATEMENT:
I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements
are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying. (Kan-
sas: This does not constitute a warranty)
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an active owner, partner or executive officer)
CO-APPLICANT’S SIGNATURE: DATE:
PRODUCER’S SIGNATURE: DATE:
IOWA LICENSED AGENT (IF APPLICABLE):
(Applicable in Iowa only)
AGENT’S NAME: AGENT’S LICENSE NUMBER:
(Applicable to Florida agents only)
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.
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HABITATIONAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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