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LESSORS RISK SUPPLEMENTAL APPLICATION (Colonial General Insurance Agency, Inc)

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GL-APP-101 (6-18) Page 1 of 7
LESSOR’S RISK SUPPLEMENTAL APPLICATION
(Complete in addition to the ACORD Application)
Applicant’s Name:
Location 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)
Location
No.
Building
No.
Address City State Zip Code
1. GENERAL INFORMATION
Location/Bldg. Location/Bldg. Location/Bldg.
Year Built:
Construction:
No. Stories:
Year Updated (Parking Areas):
Tenant’s Occupancy:
Building Square Footage:
Percentage of Building that is Vacant: %
%
%
Percentage of Building for Apartment Rental: %
%
%
Parking Area Square Footage:
GL-APP-101 (6-18) Page 2 of 7
Location/Bldg. Location/Bldg. Location/Bldg.
How are building(s) managed (Insured or Professional
Property Management Firm [PPMF]):
If applicable, is the applicant named as an
additional insured on the Property
Manager’s Policy? ...................................... Yes No
List all occupants of the building OR attach a tenant
listing/rent roll:
Does applicant occupy any part of the
premises? ................................................... Yes No
If “Yes,” is the legal entity the same? ......... Yes No
If “No,” name the legal entity:
Do they have separate insurance
coverage? ................................................... Yes No
Advise Regarding the Following Tenant Occupancies: If “Yes,” Location/Bldg.
• Academic fraternity or sorority houses ................................ Yes No
• Ammunition manufacturing and shell reloading .................. Yes No
• Anhydrous ammonia dealers .............................................. Yes No
• Apartment(s) ....................................................................... Yes No
If yes, percentage of building occupancy ............................ %
• Assisted living facilities ........................................................ Yes No
• Bar/Tavern or Nightclub ...................................................... Yes No
If yes, percentage of building occupancy ............................ %
• Gentlemens clubs ............................................................... Yes No
• Barns/Farms ........................................................................ Yes No
• Cabaret or Comedy clubs ................................................... Yes No
• Circuit board manufacturers ................................................ Yes No
• Chemical distributors ........................................................... Yes No
• Chemical manufacturing—all classes ................................. Yes No
• Church ................................................................................. Yes No
• Commercial condominium units .......................................... Yes No
If yes, percentage of building occupancy ............................ %
• Drug manufacturing—all classes ........................................ Yes No
• Explosives or fireworks manufacturers ............................... Yes No
• Flea markets and bazaars ................................................... Yes No
• Fuel or oil bulk supply stations and distribution terminals ... Yes No
• Gas manufacturers—all classes ......................................... Yes No
• Hospitals.............................................................................. Yes No
• Hotel .................................................................................... Yes No
• Lead manufacturing and lead works ................................... Yes No
GL-APP-101 (6-18) Page 3 of 7
Advise Regarding the Following Tenant Occupancies: If “Yes,” Location/Bldg.
• Office occupancy ................................................................. Yes No
If yes, percentage of building occupancy ............................ %
• Marijuana/Cannabis exposure ............................................ Yes No
• Nursing/Convalescent homes ............................................. Yes No
• Paint manufacturers ............................................................ Yes No
• Penal institutions ................................................................. Yes No
• Plastic products manufacturers ........................................... Yes No
• Rehabilitation centers .......................................................... Yes No
• Restaurant/Deli only ............................................................ Yes No
If yes, percentage of building occupancy ............................ %
If yes, BBQ restaurant ......................................................... Yes No
• Rubber manufacturing or rubber reclaiming ....................... Yes No
• Saw mill ............................................................................... Yes No
• Shopping center .................................................................. Yes No
• Teen dance clubs ................................................................ Yes No
• Tire dealers, distributors, warehousing or storage .............. Yes No
• Warehouses ........................................................................ Yes No
• Wood products manufacturing ............................................ Yes No
If yes, percentage of building occupancy ............................ %
2. FIRE/SAFETY INFORMATION
Location/Bldg. Location/Bldg. Location/Bldg.
Sprinklered? ................................................ Yes No
Percent Sprinklered:
Smoke Detectors in each unit? ................... Yes No
Hardwire or Battery (How often checked?):
Emergency Lighting? .................................. Yes No
Central Station Alarms? .............................. Yes No
Is there an elevator? ................................... Yes No
Number of Elevators:
Is an elevator maintenance agreement in
effect naming the applicant as an additional
insured with hold harmless? ....................... Yes No
Ansul System? ............................................ Yes No
Service Agreement? ................................... Yes No
GL-APP-101 (6-18) Page 4 of 7
3. SECURITY
Location/Bldg. Location/Bldg. Location/Bldg.
Is security provided? ................................... Yes No
If “Yes,” what type? Guards Cameras Other
If there are security guards present, please answer the
following questions:
Are the guards: Armed Unarmed
Are the guards: Employees
Independent Contractors
Off Duty Police
If independent contractors: Certificates of
Insurance obtained? ................................... Yes No
Applicant named as an individual insured
with hold harmless on security’s policy?..... Yes No
Have there been any previous incidents of
physical or sexual assault? ......................... Yes No
If “Yes,” please explain:
4. MAINTENANCE
Location/Bldg. Location/Bldg. Location/Bldg.
Building Maintenance/Inspection
Program? .................................................... Yes No
Parking Lot Maintenance/Inspection
Program? .................................................... Yes No
Maintenance is performed by: Employees
Subcontractors
If outside contractors: Certificates of
Insurance are obtained? ............................. Yes No
Applicant is named as an additional insured
with hold harmless on subcontractor’s
policy? ......................................................... Yes No
Snow/Ice Removal is performed by: Employees
Subcontractors
If outside contractors: Certificates of
Insurance are obtained? ............................. Yes No
Applicant is named as an additional insured
with hold harmless on subcontractor’s
policy? ......................................................... Yes No
Any renovations planned? .......................... Yes No
If “Yes,” subcontractors cost:
GL-APP-101 (6-18) Page 5 of 7
5. CONTRACTUAL INFORMATION:
Is the landlord/tenant agreement a Triple Net Lease? ................................................................................ Yes No
Certificates of Insurance required from tenants? ........................................................................................ Yes No
Tenants’ limits required to be equal to or greater than applicant’s? ............................................................ Yes No
Applicant named as additional insured on Tenants’ policies? ..................................................................... Yes No
Hold harmless agreement in place with tenants in favor of applicant? ....................................................... Yes No
6. Are there swimming or wading pools?
If “Yes”:
• Number of pools: ...................................................................................................................................
• Pools fenced? ....................................................................................................................................... Yes No
• Gates self-closing and locking? ............................................................................................................ Yes No
• Depths marked? .................................................................................................................................... Yes No
• Swimming rules posted? ....................................................................................................................... Yes No
• Life safety equipment available at poolside? ........................................................................................ Yes No
• Platforms or diving boards? ....................................................................... Yes No Height:
• Slides? ........................................................................................................ Yes No Height:
• Certified lifeguard available when swimming is allowed? ..................................................................... Yes No
• Are swimming pools, wading pools, hot tubs and spas in compliance with the federal Virginia
Graeme Baker Pool and Spa Safety Act? ............................................................................................. Yes No
7. Does risk engage in the generation of power, other than emergency backup power, for their
own use or sale to power companies?.................................................................................................... Yes No
If “Yes,” describe:
8. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If “Yes,” explain and advise where insured:
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.
GL-APP-101 (6-18) Page 6 of 7
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.
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.
GL-APP-101 (6-18) Page 7 of 7
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.
Agent Email: Preferred Method of Correspondence Email Fax Mail
Applicant Email: Preferred Method of Correspondence Email Fax Mail
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LESSORS RISK SUPPLEMENTAL APPLICATION (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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