Fillable Habitational Risks Supplemental Application (Special Risks)

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Habitational Risks Supplemental Application (Special Risks)

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The Habitational Risks Supplemental Application (Special Risks) form is 7 pages long and contains:

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  • 33 check-boxes
  • 611 other fields

Country of origin: US
File type: PDF

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A006s (11/15) Contains copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 7
Habitational Risks – Supplemental Application
TO BE USED WITH COMMERCIAL GENERAL LIABILITY/ PROPERTY APPLICATION (ACORD OR SIMLAR APPLICATION)
All questions must be answered in full. Missing or incomplete information may disqualify the submission.
Application must be signed and dated by the applicant.
Applicant Name
Agent
Applicant Mailing Address
Applicant Phone Number
Web Address
Inspection Contact
Proposed Policy Period to
Phone Number for Inspection Contact
Applicant is Individual Partnership Corporation Joint Venture Other
General Occupancy Information:
Loc #1
Loc #2
Loc #3
Type of Occupancy:
Apartment: (number of units)
1 Bedroom
2 Bedroom
3 Bedroom
Other (explain):
Animals Permitted (Y/N) (Type)
Rooming House: (number of units)
Single Room Occupancy
Double Room Occupancy
Other (explain):
Maximum Occupancy
Animals Permitted (Y/N) (Type)
Dwelling: (Indicate 1, 2, 3 or 4 Family)
Animals Permitted (Y/N) (Type)
Tenancy by % or maximum units/occupants:
Assisted Living
General population
Retirement Center
Student Occupancy (Post Secondary)
Subsidized Housing
Treatment / Recovery Facility
Are there any known aggressive dogs on premises? YES NO
If yes, an Animal Exclusion will be required
A006s (11/15) Contains copyrighted material of Insurance Services Office, Inc., with its permission. Page 2 of 7
General Building Information:
Loc #1
Loc #2
Loc #3
Year Built:
Years Owned:
Number of Stories:
Adequate means of egress from upper
floors?
YES NO
YES NO
YES NO
Emergency procedures posted?
YES NO
YES NO
YES NO
Number of Buildings:
Number of units per building
Firewall extends through roof?
YES NO
YES NO
YES NO
Number of units per firewall
Total Square Footage:
Manager on Premises?
YES NO
YES NO
YES NO
Distance to nearest fire service:
Any unoccupied or vacancy period
anticipated?
YES NO
YES NO
YES NO
Year and type of Update:
Loc #1
Loc #2
Loc #3
Paint
Parking areas
Patio Balconies or Railings
Plumbing
Roof
Type of material (shingle, wood, tile, etc.)
Sidewalks
Wiring/Electrical (Indicate by type below)
Aluminum
Breaker Box
Fuse
Knob and Tube
Pigtail wiring
Romex
Heating
A006s (11/15) Contains copyrighted material of Insurance Services Office, Inc., with its permission. Page 3 of 7
Renovation work:
Loc #1
Loc #2
Loc #3
Renovation contemplated this year?
YES NO
YES NO
YES NO
Current renovation in progress?
YES NO
YES NO
YES NO
Occupied during renovation?
YES NO
YES NO
YES NO
Type of Renovation
Estimated Cost of Renovation
Estimated Duration
Work performed by Subcontractors?
YES NO
YES NO
YES NO
Certificates on file?
YES NO
YES NO
YES NO
Additional Insured Endorsement?
YES NO
YES NO
YES NO
Special Exposures:
Use the notes section to detail any “yes” response
Loc #1
Loc #2
Loc #3
Acreage (number of acres)
YES NO
YES NO
YES NO
Balconies
YES NO
YES NO
YES NO
Bar-B-Qs permitted on balconies
YES NO
YES NO
YES NO
Railings regularly inspected
YES NO
YES NO
YES NO
Meet current building codes
YES NO
YES NO
YES NO
Common area Bar-B-Qs
YES NO
YES NO
YES NO
Beaches
YES NO
YES NO
YES NO
Clubhouse
YES NO
YES NO
YES NO
Dock, Pier or Boat Slips
YES NO
YES NO
YES NO
Equestrian Exposures
YES NO
YES NO
YES NO
Hiking or Biking Trails
YES NO
YES NO
YES NO
Lake/Pond (include size in acres)
YES NO
YES NO
YES NO
Park or Athletic Fields
YES NO
YES NO
YES NO
Playground Equipment
YES NO
YES NO
YES NO
Racquetball courts
YES NO
YES NO
YES NO
Streets or Roads
YES NO
YES NO
YES NO
Swimming Pool (Complete Supplemental Application)
YES NO
YES NO
YES NO
Volleyball or Tennis courts
YES NO
YES NO
YES NO
A006s (11/15) Contains copyrighted material of Insurance Services Office, Inc., with its permission. Page 4 of 7
Fire Protection:
Loc #1
Loc #2
Loc #3
Sprinklered? (indicate Full or Partial)
YES NO
YES NO
YES NO
Each unit equipped with:
Use the notes section to detail any “No” response
Smoke Detectors
YES NO
YES NO
YES NO
CO2 Detector
YES NO
YES NO
YES NO
Hard wire or battery
YES NO
YES NO
YES NO
If equipped w/wood burning stove or fireplace:
Use the notes section to detail any “No” response
Spark arrester on chimney
YES NO
YES NO
YES NO
Flue/chimney cleaned on regular basis
YES NO
YES NO
YES NO
Damper functional
YES NO
YES NO
YES NO
Premises located in wooded area
YES NO
YES NO
YES NO
Maintenance:
Loc #1
Loc #2
Loc #3
Exterior Maintenance Contract in place for:
General building maintenance
YES NO
YES NO
YES NO
Lawn Care
YES NO
YES NO
YES NO
Rubbish or large trash removal
YES NO
YES NO
YES NO
Sidewalk or driveway upkeep
YES NO
YES NO
YES NO
Snow Removal
YES NO
YES NO
YES NO
Interior Maintenance Contract in place for:
Appliances
YES NO
YES NO
YES NO
Carpet
YES NO
YES NO
YES NO
Electrical
YES NO
YES NO
YES NO
Fire detection systems
YES NO
YES NO
YES NO
Heating/Air Conditioning
YES NO
YES NO
YES NO
Plumbing
YES NO
YES NO
YES NO
Any work performed by subcontractors?
YES NO
YES NO
YES NO
Certificates on file
YES NO
YES NO
YES NO
Additional Insured Endorsement
YES NO
YES NO
YES NO
Specified Loss or Conditions:
Loc #1
Loc #2
Loc #3
Has there been or is there currently any:
Use the notes section to detail any “Yes” response
Fire damage (whether or not fully repaired)
YES NO
YES NO
YES NO
Mold, hidden decay
YES NO
YES NO
YES NO
Water damage
YES NO
YES NO
YES NO
Collapse
YES NO
YES NO
YES NO
Construction defect type loss?
YES NO
YES NO
YES NO
A006s (11/15) Contains copyrighted material of Insurance Services Office, Inc., with its permission. Page 5 of 7
Student Housing Complete this Section:
Loc #1
Loc #2
Loc #3
Do you rent or lease the property to any
fraternal organization, sorority, club, or other
social organization?
YES NO
YES NO
YES NO
Do you have a formal written signed lease
with all tenants?
YES NO
YES NO
YES NO
Are tenants restricted from extending
occupancy to others without your approval?
YES NO
YES NO
YES NO
Describe tenancy arrangements
(C – Co-Ed or G – Gender Specific (M/F))
C G ( M F)
C G ( M F)
C G ( M F)
Due to the nature of occupancy, do you have:
Rules regarding parties, or other
activities permitted on premises?
YES NO
YES NO
YES NO
Rules that prohibit tenants from
keeping any type of weapon on
premises?
YES NO
YES NO
YES NO
Rules that identify the definition of
“Hazing” or similar practices in
accordance with the Fraternal
Information and Programming Group
(FIPG) regardless of whether tenants
are a member of such organization?
YES NO
YES NO
YES NO
Do you provide household furnishings?
YES NO
YES NO
YES NO
If yes, do you inspect on regular basis?
YES NO
YES NO
YES NO
Do you provide security guards?
YES NO
YES NO
YES NO
If yes, Are they Armed or Unarmed
ARMED UNARMED
ARMED UNARMED
ARMED UNARMED
Hours of patrol (_ TO _ * INDICATE AM – PM ):
Do they have power of arrest?
YES NO
YES NO
YES NO
Are they employees?
YES NO
YES NO
YES NO
If Subcontractors do they name you as
Additional Insured for work performed?
YES NO
YES NO
YES NO
Certificates of insurance on File?
YES NO
YES NO
YES NO
Do all sleeping rooms have privacy locks?
YES NO
YES NO
YES NO
Do tenants share a common restroom?
YES NO
YES NO
YES NO
Are doors equipped with privacy locks?
YES NO
YES NO
YES NO
Do you provide a resident manager?
YES NO
YES NO
YES NO
Minimum Age Requirement
Yes
No
Background Checks
Yes
No
Indicate type of background checks
Local
Regional
National
A006s (11/15) Contains copyrighted material of Insurance Services Office, Inc., with its permission. Page 6 of 7
Notes Section:
Use this section to provide additional information or to detail “Yes” or “No” responses where required.
PLEASE READ BELOW AND COMPLETE SIGNATURE BLOCK ON LAST PAGE
I have reviewed this application for accuracy before signing it. As a condition precedent to coverage, I hereby state that
the information contained herein is true, accurate and complete and that no material facts have been omitted,
misrepresented or misstated. I know of no other claims or lawsuits against the applicant and I know of no other events,
incidents or occurrences which might reasonably lead to a claim or lawsuit against the applicant. I understand that this is
an application for insurance only and that completion and submission of this application does not bind coverage with any
insurer.
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 FOR THE STATE(S) OF:
Alabama, Alaska, Arizona, Arkansas, California, Connecticut, Delaware, District of Columbia, Georgia, Idaho,
Illinois, Indiana, Iowa, Louisiana, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska,
Nevada, New Hampshire, North Carolina, North Dakota, Rhode Island, South Carolina, South Dakota, Texas, Utah,
Vermont, West Virginia, Wisconsin, Wyoming: 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: 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
A006s (11/15) Contains copyrighted material of Insurance Services Office, Inc., with its permission. Page 7 of 7
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: 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.
Hawaii: Intentionally or knowingly misrepresenting or concealing a material fact, opinion or intention to obtain coverage,
benefits, recovery or compensation when presenting an application for the issuance or renewal of an insurance policy or
when presenting a claim for the payment of a loss is a criminal offense punishable by fines or imprisonment, or both.
Kansas: Any person who commits a fraudulent insurance act is guilty of a crime and may be subject to restitution, fines
and confinement in prison. A fraudulent insurance act means an act committed by 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 or insurance agent or broker, any written, electronic, electronic impulse, facsimile, magnetic,
oral or telephonic communication or statement as part of, or in support of, an application for insurance, or the rating of an
insurance policy, or a claim for payment or other benefit under an insurance policy, which such person knows to contain
materially false information concerning any material fact thereto; or conceals, for the purpose of misleading, information
concerning any fact material thereto.
Kentucky, Ohio, Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance 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.
Maine, Tennessee, Virginia, Washington: 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: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or
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: Any person who includes any false or misleading information on an application for an insurance policy is
subject to criminal and civil penalties.
New Mexico: 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 civil fines and criminal
penalties.
New York: 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 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: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents materially false information in an application for insurance may be guilty of a crime and may be subject to fines
and confinement in prison.
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Habitational Risks Supplemental Application (Special Risks)

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Completed 9 July 2021

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