Fillable Lessors Risk Only Product Application All States (Access E&S Insurance Services)

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Lessors Risk Only Product Application All States (Access E&S Insurance Services)

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YOU CAN OBTAIN A QUOTE BY PROVIDING THE INFORMATION IN SECTION I - INSTANT QUOTE BELOW, SUBJECT TO THE REMAINDER PROVIDED PRIOR TO BINDING.
LROA 10/12
page 1 of 4
Lessor’s Risk Only Product Application – All States
I. INSTANT QUOTE INFORMATION
Instant Quote is only available for accounts with no losses in the past three years. If there is loss history, please complete the entire application.
Applicant’s name: __________________________________________________________________________________________________________
Form of business: Individual Corporation Partnership LLC Other ____________________________
Location address: __________________________________________________________________________________
Same as mailing address.
City: ______________________________________________________ State: ______________________ Zip code: ___________________
Description of operations:
How many years has the applicant been at the current location? ____________________________________________________________
List the tenant(s) occupying the building: _________________________________________________________________________________
All commercial tenants, other than self insured governmental entities, are required to carry insurance and the
owner/property manager obtains certificates of insurance from all commercial tenants as evidence of
general liability True False
Applicant has a lease in place with all occupants of the building whether or not they are involved in ownership True False
The applicant occupies part of the premises True False
If “True,” please identify your operations ____________________________________________________________________________
Property Section
Construction: Frame Joisted masonry Non-combustible Masonry non-combustible
Modified fire-resistive Fire-resistive Other ___________________
Protection class: ___________
Requested cause of loss: Basic Special
Requested valuation: Replacement cost Actual cash value
Deductible: $1,000 $2,500 $5,000
Coinsurance: 80% 90% 100%
Building Limit $ __________________________________________
What year was the building constructed? ___________________
What is the square footage of the entire structure? ___________sq. ft.
Business personal property limit $ _________________________
Business income with extra expense limit $ _________________________________________
 Coinsurance per above OR Monthly limit of indemnity: 1/3 1/4 1/6
Is the building fully protected by an operational sprinkler system covering 100% of the premises? Yes No
Liability Section
Limit: $100,000/$200,000 $300,000/$600,000 $500,000/$1,000,000 $1,000,000/$2,000,000
Number of apartment units: __________________
List the square footage of any vacant area: ________________
Number of stories: ___________________
Number of years applicant has owned this building : _________________________
Additional Interests (AI = Additional Insured, LP = Loss Payee, M = Mortgagee)
Lease has a provision requiring tenant(s) to maintain general liability insurance with applicant as additional True False
insured
Lease requires tenant(s) to maintain and/or repair the premises, including keeping such premises free of snow
and ice, adjacent to the building, e.g. sidewalks, driveways, parking lots, etc. True False
Name Relationship/Interest Address City, State, Zip AI LP M



USLI.COM
USLI.COM
888-523-5545
888-523-5545
II. LOSS INFORMATION FOR THE PAST THREE YEARS
Property Coverages None, or provide detail below.
Year Status Incurred Description
_______ Open/Closed $ ______________ _____________________________________________________________________________
_______ Open/Closed $ ______________ _____________________________________________________________________________
_______ Open/Closed $ ______________ _____________________________________________________________________________
Liability Coverages None, or provide detail below.
Year Status Incurred Description
_______ Open/Closed $ ______________ _____________________________________________________________________________
_______ Open/Closed $ ______________ _____________________________________________________________________________
_______ Open/Closed $ ______________ _____________________________________________________________________________
III. ADDITIONAL PROPERTY INFORMATION
If the building is older than 10 years old, please complete the following:
Age of roof __________yrs.
Roof type: Flat Wood shake Shingle Metal Tile Slate Other ____________________
Plumbing type: PVC Copper Lead Galvanized Other _____________________
What type of burglar alarm is on the premises? Central station Local None
IV. ELIGIBILITY CRITERIA
1. Applicant is the owner of all properties True False
2. No structural renovations ongoing or planned during our policy term True False
3. No past, pending or planned bankruptcy or judgment for unpaid taxes against the named insured or any True False
officer, partner, member or owner of the applicant individually in the past five years
4. Coverage has not been cancelled or non-renewed in the last three years (not applicable in Missouri) True False
If “False,” advise reason _________________________________________________________________________________________________
5. Any building over seven stories is 100% sprinklered True False
6. Any tenant of the building a marijuana prescriber or marijuana distributor or dispensary True False
7. Any tenant of the building a bar or night club True False
Property
1. For any building built prior to 1978, 100% of the electric wiring is on functioning and
operating circuit breakers N/A True False
2. For any building built prior to 1978, there is no aluminum wiring or knob and tube wiring N/A True False
3. Functioning and operational smoke detectors in all units and/or occupancies True False
4. Functioning and operational fire extinguishers readily available True False
5. Any building over 7 stories is 100% sprinklered True False
6. No tenant is a marijuana distributor or dispensary True False
General Liability
1. No commercial cooking with extinguishing systems not in compliance with NFPA #96 N/A True False
2. No tenant is a medical marijuana grower, hospital, nursing home, assisted
living facility, elder care facility or any health care facility with an overnight or residential exposure True False
3. Any building over seven stories is 100% sprinklered True False
4. No structural renovations are on going or planned during policy term True False
5. Certificate of insurance required from all contractors naming the applicant as additional insured True False
V. ADDITIONAL APPLICANT INFORMATION
Applicant’s mailing address: ____________________________________________________ (if different than the location address above)
City: ______________________________________________________ State: ______________________ Zip: ________________________
E-mail address of primary contact: _____________________________________________ Phone: ____________________________________
Inspection contact name: _______________________________________ Telephone/E-mail address: ___________________________________
FRAUD STATEMENTS
Arizona Notice: Misrepresentations, omissions, concealment of facts and incorrect statements shall prevent recovery under the policy only if the misrepresentations,
omissions, concealment of facts or incorrect statements are; fraudulent or material either to the acceptance of the risk, or to the hazard assumed by the insurer or
the insurer in good faith would either not have issued the policy, or would not have issued a policy in as large an amount, or would not have provided coverage with
respect to the hazard resulting in the loss, if the true facts had been made known to the insurer as required either by the application for the policy or otherwise.
Colorado Fraud Statement: 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 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.
District of Columbia Fraud Statement: WARNING: 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.
LROA 10/12
page 2 of 4
Florida Fraud Statement: 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.
FLORIDA NOTICE FOR NON ADMITTED POLICIES ONLY: You are agreeing to place coverage in the surplus lines market. Superior coverage may be available
in the admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act with respect to any
right of recovery for the obligation of an insolvent unlicensed insurer.
Florida and Illinois Notice: I understand that there is no coverage for punitive damages assessed directly against an insured under Florida and Illinois law.
However, I also understand that punitive damages that are not assessed directly against an insured, also known as “vicariously assessed punitive damages”,
are insurable under Florida and Illinois law. Therefore, if any Policy is issued to the Applicant as a result of this Application and such Policy provides coverage for
punitive damages, I understand and acknowledge that the coverage for Claims brought in the State of Florida and Illinois is limited to “vicariously assessed punitive
damages” and that there is no coverage for directly assessed punitive damages.
Kansas Fraud Statement: 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, broker or any agent thereof, any written statement 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 conceals, for the purpose of misleading,
information concerning any fact material thereto may be guilty of a crime and may be subject to fines and confinement in prison.
Kentucky Fraud Statement: 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 and Washington Fraud Statement: 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 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.
Authorization or agreement to bind the insurance may be withdrawn or modified only based on changes to the information contained in this application prior to the
effective date of the insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10 days notice given to the
insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for nonpayment of premium.
MISSOURI SPECIAL NOTICE - FOR REAL ESTATE PRODUCTS SOLD IN MISSOURI
Missouri Disclosure Notice: I understand and acknowledge that as respects Discrimination and Lock Box coverage that Claims Expenses are a part of the Limit of
Liability. This means that Claims Expenses will reduce my limits of insurance and may exhaust them completely and should that occur; I shall be liable for any further
Claims Expenses. Claims Expenses are as defined in Section VII. I also understand that the Limit of Liability for the Extended Reporting Period, if applicable, shall
be a part of and not in addition to the limit specified in the Policy Declarations.
MISSOURI SPECIAL NOTICE - FOR SUPERTEK AND MICROTEK PRODUCTS SOLD IN MISSOURI
Missouri Disclosure Notice: I understand and acknowledge that Claims Expense or defense costs are a part of the limits of insurance for the MicroTek product. I
also understand and acknowledge that Claims Expenses are part of the limits of insurance for Intellectual Property Claims coverage, if chosen, under the Technology
product. Any defense costs paid under this coverage part will reduce the available limits of insurance and may exhaust them completely. Defense costs means
reasonable and necessary fees, costs and expenses resulting solely from the investigation, legal defense and legal appeal of a claim against the Insured, but
excluding salaries of officers and employees of the Insurer.
MISSOURI SPECIAL NOTICE - FOR EPL, CORPORATE D&O AND NON PROFIT D&O PRODUCTS SOLD IN MISSOURI
Missouri Disclosure Notice: I understand and acknowledge that if a $100,000 or $250,000 Limit of Liability is chosen or if the Insured Organization has more than
200 employees, that Defense Costs are a part of the Limit of Liability. This means that Defense Costs will reduce my limits of insurance and may exhaust them
completely and should that occur, I shall be liable for any further legal Defense Costs and Damages. Defense Costs are as defined in Section III. I also understand
that the Limit of Liability for the Extended Reporting Period, if applicable, shall be a part of and not in addition to the limit specified in the Policy Declarations.
MISSOURI SPECIAL NOTICE - FOR COMMUNITY ASSOCIATIONS PRODUCT SOLD IN MISSOUri
Missouri Notice: Pursuant to Section IV, Paragraph R., some Defense Costs are within the Limit of Liability. Any Defense Costs paid under this coverage will
reduce the available Limits of Insurance and may exhaust them completely. Defense Costs means reasonable and necessary legal fees and expenses incurred by
the Company, or by any attorney designated by the Company to defend any Insured, resulting from the investigation, adjustment, defense and appeal of a Claim.
Defense Costs includes other fees, costs, costs of attachment or similar bonds (without any obligation on the part of the Company to apply for or furnish such
bonds), but does not include salaries, wages, overhead or benefits expenses of any Insured.
New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil
penalties.
New York Disclosure Notice: This policy is written on a claims made basis and shall provide no coverage for claims arising out of incidents, occurrences or alleged
Wrongful Acts or Wrongful Employment Acts that took place prior to retroactive date, if any, stated on the declarations. This policy shall cover only those claims
made against an insured while the policy remains in effect for incidents reported during the Policy Period or any subsequent renewal of this Policy or any extended
reporting period and all coverage under the policy ceases upon termination of the policy except for the automatic extended reporting period coverage unless the
insured purchases additional extend reporting period coverage. The policy includes an automatic 60 day extended claims reporting period following the termination
of this policy. The Insured may purchase for an additional premium an additional extended reporting period of 12 months, 24 months or 36 months following the
termination of this policy. Potential coverage gaps may arise upon the expiration for this extended reporting period. During the first several years of a claims-made
relationship, claims-made rates are comparatively lower than occurrence rates. The insured can expect substantial annual premium increases independent overall
rate increases until the claims-made relationship has matured.
North Dakota Fraud Statement: Notice to North Dakota applicants – Any person who knowingly and with the intent to defraud and insurance company or other
person, files an application for insurance or statement of claim containing any materially false information, or conceals for t
he 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.
Ohio Fraud Statement: 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.
I understand that any material misrepresentation or omission made by me on this application may act to render any contract of insurance null and without effect or
provide the company the right to rescind it.
By acceptance of this policy, the Insured agrees the statements in the application (new or renewal) submitted to the company are true and correct. It is
understood and agreed that, to the extent permitted by law, the Company reserves the right to rescind this policy, or any coverage provided herein, for material
misrepresentations made by the Insured. It is understood and agreed that the statements made in the insurance applications are incorporated into, and shall form
part of, this policy.
Oklahoma Fraud Statement: 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 Fraud Statement: Notice to Oregon applicants: Any person who, with intent to defraud or knowing that he is facilitation facilitating a fraud against an
insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
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.
RHODE ISLAND SPECIAL NOTICE - FOR REAL ESTATE PRODUCTS SOLD IN RHODE ISLAND
Rhode Island Disclosure Notice: I understand and acknowledge that as respects Discrimination and Lock Box coverage that Claims Expenses are a part of the
Limit of Liability. This means that Claims Expenses will reduce my limits of insurance and may exhaust them completely and should that occur; I shall be liable
for any further Claims Expenses. Claims Expenses are as defined in Section VII. I also understand that the Limit of Liability for the Extended Reporting Period, if
applicable, shall be a part of and not in addition to the limit specified in the Policy Declarations.
LROA 10/12
page 3 of 4
RHODE ISLAND SPECIAL NOTICE - FOR SUPERTEK AND MICROTEK PRODUCTS SOLD IN RHODE ISLAND
Rhode Island Disclosure Notice: I understand and acknowledge that Claims Expenses are a part of the Limit of Liability for the MicroTekPak product.
I also understand and acknowledge that Claims Expenses are part of the Limit of Liability for Intellectual Property Claims coverage, if chosen, under the
Technology product. This means that Claims Expense will reduce my limits of insurance and may exhaust them completely and should that occur, I shall
be liable for any further Claims Expense. Claims Expense is as defined in the DEFINITIONS section of the policy form. Intellectual Property Claims are as
defined in Section III of the Broad Form Endorsement for the Technology product. I also understand that the Limit of Liability for the Extended Reporting
Period, if applicable, shall be a part of and not in addition to the limit specified in the Policy Declarations.
RHODE ISLAND SPECIAL NOTICE - FOR EPL, CORPORATE D&O AND NON PROFIT D&O PRODUCTS SOLD IN RHODE ISLAND
Rhode Island Disclosure Notice: I understand and acknowledge that if a $100,000 or $250,000 Limit of Liability is chosen or if the Insured Organization
has more than 200 employees, that Defense Costs are a part of the Limit of Liability. This means that Defense Costs will reduce my limits of insurance
and may exhaust them completely and should that occur, I shall be liable for any further legal Defense Costs and Damages. Defense Costs are as defined
in Section III. I also understand that the Limit of Liability for the Extended Reporting Period, if applicable, shall be a part of and not in addition to the limit
specified in the Policy Declarations.
Tennessee and Virginia Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Utah Notice: I understand that Punitive Damages are not insurable in the state of Utah. There will be no coverage afforded for Punitive Damages for
any Claim brought in the State of Utah. Any coverage for Punitive Damages will only apply if a Claim is filed in a state which allows punitive or exemplary
damages to be insurable. This may apply if a Claim is brought in another state by a subsidiary or additional location(s) of the Named Insured, outside the
state of Utah, for which coverage is sought under the same policy
Vermont Fraud Statement: 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 may be subject to fines and confinement in prison.
Virginia Notice: This Policy is written on a claims-made basis. Please read the policy carefully to understand your coverage. You have an option to
purchase a separate limit of liability for the extended reporting period. If you do not elect this option, the limit of liability for the extended reporting period
shall be part of the and not in addition to limit specified in the declarations. If you have any questions regarding the cost of an extended reporting period,
please contact your insurance company or your insurance agent. Statements in the application shall be deemed the insured’s representations. A statement
made in the application or in any affidavit made before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly
proven that such statement was material to the risk when assumed and was untrue.
Virginia Fraud Statement: Any person who knowingly and with intent to defraud an insurer, submits an Application for insurance or files a claim
containing a false or deceptive statement is guilty of insurance fraud.
Utah Fraud Statement: 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.
Washington Fraud Statement: Any person, who, knowing it to be such:
(1) Presents, or causes to be presented, a false or fraudulent claim or any proof in support of such a claim, for the payment of a Loss under a contract of
insurance; or
(2) Prepares, makes, or subscribes any false or fraudulent account, certificate, affidavit, or proof of Loss, or other document or writing, with intent that it
be presented or used in support of such a claim, is guilty of a gross misdemeanor, or if such claim is in excess of one thousand five hundred dollars, of a
class C felony.
Fraud Statement (All Other States): 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.
Retail agency name:________________________________________________ License #: _________________________________
Main agency phone number: ____________________________________________
Agency mailing address: _______________________________________________________________________________________
City: _______________________________________________ State: _______________________ Zip: ______________________
The signer of this application acknowledges and understands that the information provided in this Application is material to the
Insurer’s decision to provide the requested insurance and is relied on by the Insurer in providing such insurance. The signer of this
application represents that the information provided in this Application is true and correct in all matters. The signer of this Application
further represents that any changes in matters inquired about in this Application occurring prior to the effective date of coverage,
which render the information provided herein untrue, incorrect or inaccurate in any way will be reported to the Insurer immediately in
writing. The Insurer reserves the right to modify or withdraw any quote or binder issued if such changes are material to the insurability
or premium charged, based on the Insurer’s underwriting guides. The Insurer is hereby authorized, but not required, to make any
investigation and inquiry in connection with the information, statements and disclosures provided in this Application. The decision of
the Insurer not to make or to limit any investigation or inquiry shall not be deemed a waiver of any rights by the Insurer and shall not
estop the Insurer from relying on any statement in this Application in the event the Policy is issued. It is agreed that this Application
shall be the basis of the contract should a policy be issued and it will be attached and become a part of the Policy.
New York Fraud Statement: 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 signature: ____________________________________________ Title: _________________________
Date: ___________________________________________________________
Officer of the Board or Property Manager
LROA 10/12
page 4 of 4
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Lessors Risk Only Product Application All States (Access E&S Insurance Services)

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Completed 8 January 2021

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