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COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION – PROPERTY - UNPROTECTED - SUPPLEMENTAL APPLICATION
ACORD Application also required - Check all applicable checkboxes below
General Agent:
Date:
Insured:
Insured Mailing Address:
Insured’s Web Address:
Insured Contact Name:
Phone Number:
SUBMIT
Protection Class 9
Protection Class 10
LOSS HISTORY / EVICTIONS / VIOLATIONS
Three years of loss history information on ACORD application or attached to this application
Eviction(s) in past three years If yes, how many? _______
Violations of any city, county or state housing codes in past three years
EXPOSURES / CONTROLS
At least one paved road provides access to insured buildings/structures
Insured structures without at least one paved road are what distance from a paved road: ______ miles
Specifically, which insured structures: ___________________________________________________________
Paid Fire Department – or -
Volunteer Fire Department
Fire department is equipped with both pumper trucks and tanker trucks
Response time estimated to be (in minutes): _________
Insured structures are accessible to a responding fire department year round
Physical barriers, such as locked gate(s) would impact a responding fire department
Hydrants are located within 1000 feet of insured structures
If no hydrants describe any on site sources of water that could be used to fight a fire:
______________________________________________________________________________________
Estimate of total gallons of water available from on site sources listed above: ________ gallons
Maximum distance of on site water source from an insured structure is __________ feet
Premises occupied or visited daily by either insured or employee(s)
Structures that are insured for property are visible to neighbors
Central station fire alarm system
Central station burglary system
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PROPERTY - UNPROTECTED - SUPPLEMENTAL APPLICATION
GENERAL FRAUD STATEMENT (Not applicable in all states.)
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, may be committing a fraudulent insurance act, and may be subject to
a civil penalty or fine.
The undersigned is an authorized representative of the applicant and certifies that reasonable inquiry has been made to
questions on this application. He/She certifies:
The answers are true, correct and complete to the best of his/her knowledge.
They agree to the Privacy and Fraud provisions found in the ACORD-125 (Commercial Insurance Application)
and understand those provisions also apply to this supplemental application.
SIGN AND DATE
PRODUCER’S SIGNATURE DATE
APPLICANT’S PRINTED NAME DATE
APPLICANT’S SIGNATURE DATE
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