Fillable Habitational Application (RT Specialty)

Fill Online, Printable, Fillable, Blank Habitational 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.

Habitational Application (RT Specialty)

On average this form takes 197 minutes to complete

The Habitational Application (RT Specialty) form is 9 pages long and contains:

  • 3 signatures
  • 158 check-boxes
  • 701 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
Habitational Application
Applicant’s Name:
Mailing Address:
Agency Name:
Agent:
Address:
E-mail:
Phone No.:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
PLEASE 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 Number:
Is applicant a Real Estate or Property Management company? ........................................................................ Yes No
Limits Of Liability & 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 premise) $
Medical Expense (any one person) $
Other Coverages, Restrictions, and/or Endorsements:
$
Deductible $
GLS-APP-16s (10-13) Page 1 of 9
Submit Application
1. 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:
2. Description Of Locations:
Provide Detail Per Location Loc. No. 1 Loc. No. 2 Loc. No. 3 Loc. No. 4 Loc. No. 5
Years owned
Type of occupancy*
Year built
No. Stories
No. Units—total
No. Buildings
Total square feet
Type of roof
Pool? (see Section 12.) Yes No Yes No Yes No Yes No Yes No
Manager on premises? Yes No Yes No Yes No Yes No Yes No
If occupancy is other than habi-
tational, please describe the
occupancy and square footage.
Monthly rent per unit:
Apartments: 1 BR $
$
$
$
$
2 BR $
$
$
$
$
3 BR $
$
$
$
$
Other $
$
$
$
$
Dwellings: $
$
$
$
$
Percent of units subsidized
%
%
%
%
%
Percent of university or
college students as tenants
%
%
%
%
%
Vacant? 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
Subcontracted work—
Anticipated cost next twelve (12)
months
$ $ $ $ $
*Use alpha code listed for type of occupancy: A—Apartment Building F—Dwelling/three family
B—Garden Apartments G—Dwelling/four family
C—Apartment hotel H—Boarding or Rooming House
D—Dwelling/one family I—Mobile Home
E—Dwelling/two family J—Time-share
3. If occupancy is Mobile Home, are they tied down? ............................................................................... Yes No
4. Are any of the properties assisted living facilities? .............................................................................. Yes No
GLS-APP-16s (10-13) Page 2 of 9
5. Are any of the properties nursing/convalescent homes? ..................................................................... Yes No
6. Are any of the properties senior housing? ............................................................................................. Yes No
7. Are any of the properties housing authorities? ..................................................................................... Yes No
If yes, explain:
8. Do any of the properties include subsidized housing (including HUD and Section 8)? .................... Yes No
If yes, advise location(s) and number of units:
9. Is any dwelling location owner occupied?.............................................................................................. Yes No
10. Number of years in business?
11. Year Of Updates:
Provide Year &
Indicate Full or Partial
Update Per Location
Loc. No. 1 Loc. No. 2 Loc. No. 3 Loc. No. 4 Loc. No. 5
Heating
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
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
Plumbing
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
Roof
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
Wiring & Electrical
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
12. Current Renovations:
Provide Detail Per Location Loc. No. 1 Loc. No. 2 Loc. No. 3 Loc. No. 4 Loc. No. 5
Cost of renovation $
$
$
$
$
Type of renovation
Certificates for subcontractors on
file?
Yes No Yes No Yes No Yes No Yes No
GLS-APP-16s (10-13) Page 3 of 9
13. Swimming Pool(s):
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
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
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
Underwater lighting? Yes No Yes No Yes No Yes No Yes No
Steps into shallow end with hand-
rails?
Yes No Yes No Yes No Yes No Yes No
Ladder at deep end with handrails? 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
14. Maintenance:
Who performs:
Janitorial operations? ...................................................................................................... Contractor Employee
Lawn care operations? .................................................................................................... Contractor Employee
Upkeep of sidewalks and driveways? ............................................................................. Contractor Employee
Snow/ice removal operations? ........................................................................................ Contractor Employee
For all operations performed by an outside contractor:
Are certificates of insurance on file? ..................................................................................................... Yes No
Is the applicant named as additional insured on their policy? .............................................................. Yes No
15. Fire Protection:
a. Sprinklered? ........................................................................................................................................ Yes No
If yes: All units? ................................................................................................................................... Yes No
Common areas? ....................................................................................................................... Yes No
GLS-APP-16s (10-13) Page 4 of 9
Fire Protection continued:
b. Smoke detectors in each unit? .......................................................................................................... Yes No
If yes: Hard-wire or battery? How often checked?
c. Fire extinguishers? ............................................................................................................................. Yes No
If yes: In each unit? ............................................................................................................................. Yes No
In common areas? ................................................................................................................... Yes No
d. Number of units per fire division: .........................................................................................................
16. Security:
Completion of Section 15. Security not required for dwelling or boarding/rooming house occupancies.
a. Master keys and locks:
(1) How does management handle the monitoring of master keys?
(2) How are locks handled upon vacancy of residents? ................................ Re-keyed Changed completely
b. Criminal incidents:
(1) Does management advise residents of all criminal activity that has taken place on the
properties? ......................................................................................................................................
Yes No
If yes, how is this done?
(2) Is this information provided to prospective renters if requested? ................................................... Yes No
c. Do the residents’ doors or windows contain any of the following?
Provide Detail Per Location Loc. No. 1 Loc. No. 2 Loc. No. 3 Loc. No. 4 Loc. No. 5
Dead bolts? 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
d. Is security provided? .......................................................................................................................... Yes No
If yes, what type? Gated access Patrol Security alarm systems
(1) If gated, please answer the following questions:
Provide Detail Per Location Loc. No. 1 Loc. No. 2 Loc. No. 3 Loc. No. 4 Loc. No. 5
Entire apartment complex gated? Yes No Yes No Yes No Yes No Yes No
Who is given access?
How is access obtained: guard at gate,
card or security code?
Guard
Card
Code
Guard
Card
Code
Guard
Card
Code
Guard
Card
Code
Guard
Card
Code
If guard at gate, advise how many
and if armed or
unarmed.
No.
Armed
Unarmed
No.
Armed
Unarmed
No.
Armed
Unarmed
No.
Armed
Unarmed
No.
Armed
Unarmed
If gate is card or security code ac-
cess, how often is maintenance
done on the gate?
What procedure is in place if gate is
not working?
GLS-APP-16s (10-13) Page 5 of 9
(2) If patrol, please answer the following questions:
Provide Detail Per Loc.
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?
Management
Contractor
Management
Contractor
Management
Contractor
Management
Contractor
Management
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
Security twenty-four (24)
hours?
Yes No Yes No Yes No Yes No Yes No
Are guards responsible
for residents’ safety
and/or complex/
amenities?
Yes No Yes No Yes No Yes No Yes No
(3) If security alarm systems are provided, please answer the following questions:
Provide Detail Per Loc. Loc. No. 1 Loc. No. 2 Loc. No. 3 Loc. No. 4
Loc. No. 5
Alarm systems in every unit? Yes No Yes No Yes No Yes No Yes No
Residents shown how to
operate the alarm systems?
Yes No Yes No Yes No Yes No Yes No
Who monitors the alarms?
17. 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)
Other:
Are any of these exposures available to nonresidents for a fee? ............................................................... Yes No
If yes, annual receipts: .............................................................................................................................. $
18. 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:
19. Any prior losses due to mold? ................................................................................................................. Yes No
If yes, has mold been completely remediated? ........................................................................................... Yes No
20. 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:
GLS-APP-16s (10-13) Page 6 of 9
21. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
22. Any new ground up construction operations anticipated within the next twelve (12) months? ...... Yes No
If yes, describe:
23. Any construction or remodeling operations for conversion to or from condominiums and/or
townhouses? ..............................................................................................................................................
Yes No
24. Additional Insured Information:
Name
Address
Interest
25. Prior Carrier Information:
Year:
Year:
Year:
Year:
Year:
Carrier
Policy Number
Coverage
Total Premium $
$
$
$
$
26. 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 to Oregon.)
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.
GLS-APP-16s (10-13) Page 7 of 9
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 of 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 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 AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for commercial insurance or a statement of claim for any commercial or per-
sonal insurance benefits containing any materially false information, or conceals for the purpose of misleading, infor-
mation concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly
makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, dam-
age or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance
company, 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 value of the subject motor vehicle or stated claim for each violation.
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 civil penalty not to exceed five thousand dollars
and the stated value of the claim for each such violation.
GLS-APP-16s (10-13) Page 8 of 9
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 state-
ments are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying.
(Kansas: 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):
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.
GLS-APP-16s (10-13) Page 9 of 9
click to sign
signature
click to edit
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

Habitational 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