Fillable New Business Application - Condo - HOA Association36-9540 - Application - Condominium-Homeowner Association - DO Flex Prot plus

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New Business Application - Condo - HOA Association36-9540 - Application - Condominium-Homeowner Association - DO Flex Prot plus

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CONDOMINIUM / HOMEOWNER ASSOCIATION
DIRECTORS & OFFICERS LIABILITY APPLICATION
DIRECTORS & OFFICERS FLEXI PROTECTION PLUS INSURANCE POLICY
THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY.
PLEASE READ YOUR POLICY CAREFULLY.
Condominium/Homeowner Association Directors & Officers Liability coverage
can only be bound in conjunction with a PHLY package policy.
This coverage is not available in CA & FL.
INSTRUCTIONS
• Whenever used in this Appliction, the term Applicant shall mean the association and all its subsidiaries.
• The Applicant is required to complete all questions.
• Please include annual budget or financial statements and any other requested underwriting information
and attachments. Failure to supply may result in delay.
1. Name of Applicant:
2. Address:
3. Date Incorporated:
4. Has all proposed construction been completed? Yes No
Date completed:
5. Type of Association:
Condominium Homeowner Association Timeshare / Interval
Cooperative Property Owners Association Master Association
6. Provide a list of all direct and indirect subsidiaries or any other entity or organization the Applicant controls:
Name / Type of Business
Percent the
Applicant Owns / Controls
Date Created /
Acquired
For Profit /
Non-Profit
Example: ABC Foundation, Inc.
100% 1/1/2012 Non-Profit
Additional entities listed by attachment.
7. Annual Budget: $
8. Has the Applicant had a negative fund balance within the last three years? Yes No
9. Are any special assessments being contemplated? If yes, indicate the reason: Yes No
Condo / HOA D&O Application
Page 1 of 4
©2013 Philadelphia Consolidated Holding Corp.
11/2013
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10. Total number of units / lots at final build-out:
a. Total number of units built currently: Lots sold currently:
b. Total number of units rented / leased:
c. Are any units rented on a daily or weekly basis? Yes No
If yes, how many:
d. Does any person or entity including, but not limited to the builder or developer, own
multiple units comprising more than 10% of the total number of units?
Yes
No
11. Average unit value: <$500,000 Over $500,000 but under $1,000,000 Over $1,000,000
12. Does the Applicant have any employees? Yes No
If yes, how many:
13. Is there an investor who owns units for investment or rental purposes on the board? Yes No
14. Is there a Sponsor / Developer / Builder or their representative on the board? Yes No
15. Does the Developer control the board? Yes No
16. Does the Applicant contract with an independent professional management company to
manage the association?
Yes
No
If yes, complete the information below:
Name of the management company:
Address:
Telephone, Fax, Website address:
17. Does the property manager have voting rights? Yes No
18. Has any board election been challenged in the last twenty-four months? Yes No
If yes, provide details:
19. Has the Applicant placed any liens against any unit owners in the last twenty-four
months? If yes, provide details for each lien:
Yes
No
20. Has the Applicant completed a foreclosure sale against a unit owner in the last twenty-
four months? If yes, provide details:
Yes
No
21. Does the Applicant have known construction defect issues? If yes, provide details: Yes No
22. Has the Applicant taken legal action against the developer due to construction defect
issues? If yes, provide details:
Yes No
Condo / HOA D&O Application
Page 2 of 4
©2013 Philadelphia Consolidated Holding Corp.
11/2013
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23. Current Coverage:
COVERAGES
Insurance Company
Limit of
Liability
Deductible
Policy Effective
Dates
Premium
D&O
$ $ $
General Liability
$ $ $
a. With respect to the above coverage, has any insurance company refused, canceled,
or non-renewed coverage? (Not applicable in Missouri) If yes, provide details:
Yes
No
b. Directors & Officers Liability insurance has been continuously in force since:
24. Has the Applicant given written notice under the provisions of any prior policies providing
similar insurance or claims, or of specific facts or circumstances which might give rise to a
claim being made against any person or entity applying for this insurance?
Yes
No
If yes, complete a Supplemental Claim form for each incident.
25. At the present time, or at the time for which you first applied for coverage as stated in 23a.
above, whichever is earlier, no person applying for this coverage is or was aware of any
facts or circumstances which he or she has reason to suppose might give rise for a future
claim what would fall within the scope of any of the proposed coverage for which the
Applicant has applied except: None
Unless None is checked, complete a Supplemental Claim form for each incident.
Yes
No
It is agreed that with respect to Questions 24. and 25. above, that if any answer is in the affirmative, then such
Claim, proceeding, or action and any Claim or action arising from such Claim, proceeding, action, knowledge,
information or involvement is excluded from the proposed coverage.
26. Material Change
If there is any material change to the answers of this Application’s questions prior to the policy inception
date, the Applicant must notify the Underwriter in writing. Any outstanding quotation may be modified or
withdrawn.
Condo / HOA D&O Application
Page 3 of 4
©2013 Philadelphia Consolidated Holding Corp.
11/2013
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FRAUD NOTICE STATEMENTS
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 AND
SUBJECTS THAT PERSON TO CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A
FRAUDULENT INSURANCE ACT WHICH MAY BE A C RIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL
PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS ($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION).
(NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A L OSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE
INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN
PRISON.
APPLICABLE IN 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 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.
APPLICABLE IN FLORIDA AND OKLAHOMA: 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 (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: 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 COMMITS A FRAUDULENT INSURANCE ACT.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A C RIME 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.
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her
knowledge and belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments
submitted with this Application) are true and complete and may be relied upon by Company * in quoting and issuing the
policy. If any of the information in this Application changes prior to the effective date of the policy, the Applicant will notify
the Company of such changes and the Company may modify or withdraw the quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR
EXECUTIVE DIRECTOR)
____________________________________________________
SIGNATURE DATE
Produced By: (Section to be completed by Producer/Broker)
PRODUCER AGENCY
PRODUCER LICENSE NUMBER AGENCY TAXPAYER ID OR SS NUMBER
ADDRESS (STREET, CITY, STATE, ZIP)
Condo / HOA D&O Application
Page 4 of 4
©2013 Philadelphia Consolidated Holding Corp.
11/2013
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