Fillable LANDOWNERS PROGRAM SUPPLEMENTAL APPLICATION (Colonial General Insurance Agency, Inc)

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LANDOWNERS PROGRAM SUPPLEMENTAL APPLICATION (Colonial General Insurance Agency, Inc)

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GL-APP-50s (3-18) Page 1 of 4
LANDOWNERS PROGRAM SUPPLEMENTAL APPLICATION
(Complete in addition to ACORD General Liability Application)
Applicant’s Name:
Mailing Address:
Agency Name:
Agent No.:
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)
A. Land Use and Acreage:
1. Indicate location address and total acreage in applicable column:
Loc.
No.
Location Address
Vacant Land
(acreage)
Real Estate
Development
Property
(acreage)
Land Leased
to Others
(acreage)
1
2
3
2. What was the prior use of the land?
3. Is applicant involved in or exposed to any hydraulic fracturing or hydrofracking operations? Yes No
If yes, describe:
4. Is land zoned for residential use? ..................................................................................................... Yes No
5. Was land ever used as a landfill? ...................................................................................................... Yes No
6. Is land an EPS Superfund site? ......................................................................................................... Yes No
7. Is land a hunting preserve? ............................................................................................................... Yes No
8. Is land used for snowmobiling or motorized vehicles and bikes? ................................................ Yes No
9. Are there logging or lumbering operations on owned or leased land? ........................................ Yes No
10. Any underground fuel tanks on the property? ................................................................................ Yes No
GL-APP-50s (3-18) Page 2 of 4
11. Any below ground mines on the property? ...................................................................................... Yes No
If yes: Sealed Not Sealed
12. Any water wells on the property? ..................................................................................................... Yes No
If yes: Sealed Not Sealed
Describe:
13. Any oil or gas wells on the property? ............................................................................................... Yes No
If yes: Sealed Not Sealed
14. Are there any buildings or equipment on the property? ................................................................ Yes No
If yes, describe:
15. Any dams on the property? ............................................................................................................... Yes No
If yes, complete Dam Questionnaire, GLS-113.
16. Any lakes on the property? ................................................................................................................ Yes No
If yes, number of acres: .........................................................................................................................
17. Does applicant have other business ventures for which coverage is not requested? ............... Yes No
If yes, explain and advise where insured:
B. Real Estate Development Property:
1. Nature of planned development:
Residential:
Total number of planned homes and/or home sites:
Townhomes or Condominiums? ..................................................................................................... Yes No
Commercial
Other:
2. Describe the work to be done:
3. Has site preparation work been completed? ................................................................................... Yes No
If yes, by whom?
4. Expected start date: Expected completion date:
5. Estimated cost for renovation/construction operations:
During next twelve (12) months: .......................................................................................................... $
For entire project: ................................................................................................................................. $
6. Who is performing the work? Licensed contractor Applicant acting as general contractor
Other:
If licensed contractor, provide name and address:
7. Are certificates of insurance obtained from the contractor or subcontractors? ......................... Yes No
(a) Does applicant obtain a written contract from the contractor or subcontractors which includes a
hold-harmless clause in favor of the applicant? ............................................................................. Yes No
(b) Is applicant named as an additional insured on the contractors or subcontractors policy? ........... Yes No
(c) Minimum limits required for a subcontractor’s policy:
GL-APP-50s (3-18) Page 3 of 4
C. Land Leased to Others—Tenant’s Use of the Land:
Camping Dirt Biking Fishing Hiking Landfill Quarry
Cross Country Skiing Farming Grazing Hunting Parking Strip Mining
Other (describe):
1. Is the tenant insured? ......................................................................................................................... Yes No
2. Does applicant obtain evidence of insurance from the tenant naming the applicant as an ad-
ditional insured on the tenant’s policy? ........................................................................................... Yes No
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-50s (3-18) Page 4 of 4
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 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 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)
PRODUCER’S SIGNATURE: DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IOWA LICENSED AGENT:
(Applicable in Iowa Only)
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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LANDOWNERS PROGRAM SUPPLEMENTAL APPLICATION (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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