Fillable Real Estate Property Management Supplemental Application (RT Specialty)

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Real Estate Property Management Supplemental Application (RT Specialty)

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The Real Estate Property Management Supplemental Application (RT Specialty) form is 6 pages long and contains:

  • 3 signatures
  • 7 check-boxes
  • 281 other fields

Country of origin: US
File type: PDF

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National Casualty Company
Home Office: Madison, Wisconsin
Adm Office: 8877 Gainey Center Dr.
Scottsdale, Arizona 85258
Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675 • Fax (480) 483-6752
www.scottsdaleins.com
Real Estate Property Management Supplemental Application
(Complete in addition to ACORD General Liability Application)
Applicant’s Name:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
PLEASE ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE”
APPLICANT PREMISES OPERATIONS INFORMATION
1. Named Insured as it is to appear on policy:
2. Doing Business As:
3. Mailing Address:
4. Location of business (if different):
City: State: Zip Code: Phone Number:
5. Contact person: Title:
Daytime phone: Nighttime phone: Fax Number:
6. Website Address:
7. Does applicant operate any type of business other than that requested by this application?......... Yes No
If yes, describe:
If yes, is this business covered separately for General Liability? ................................................................ Yes No
8. Any buildings managed over six stories high? ...................................................................................... Yes No
Total number of stories:
If yes: a. Are all life safety standards met? ............................................................................................. Yes No
b. Is an elevator maintenance agreement in place? .................................................................... Yes No
c. Is the construction Masonry-noncombustible construction or better? ..................................... Yes No
d. Are the buildings sprinklered? .................................................................................................. Yes No
9. If managing properties with pool exposures, confirm the following:
a. Are pools fenced with self-latching gates? ............................................................................................ Yes No
b. Are rules, hours and depth markers posted? ........................................................................................ Yes No
c. Are pools/spas in compliance with the Virginia Graeme Baker Pool and Spa Safety Act? .................. Yes No
d. Is life safety equipment available? ........................................................................................................ Yes No
GLZ-SUPP-1g (6-13) Page 1 of 6
Submit Application
(e) Do any pools have diving boards? ........................................................................................................ Yes No
If yes, are the boards/platforms over one meter in height? .................................................................. Yes No
Height of boards/platforms:
10. What percentage of units managed is Applicant involved in placement of tenants? ..................................... %
11. Does applicant have an ownership interest in any of the properties you managed? ........................ Yes No
If yes, provide a list on a separate sheet, of all the properties you have any ownership interest in and the percentage
of ownership in each one.
12. Does applicant obtain verification of General Liability Coverage from all owners of sites man-
aged with limits of at least $1,000,000 per Occurrence/$1,000,000 Personal & Advertising Inju-
ry/$2,000,000 General Aggregate? ...........................................................................................................
Yes No
If yes, indicate how liability coverage is verified:
The property manager is responsible for maintaining coverage.
The property manager requires certificates of insurance from the owners of properties managed.
Other—explain:
13. Is applicant listed as additional insured on property management customers’ policies? ................ Yes No
14. What amount of authority does applicant have for capital improvements and repairs? .................. $
15. Does applicant obtain a credit report for each prospective tenant? ................................................... Yes No
16. Does applicant follow formal written procedures in processing tenant evictions? ........................... Yes No
17. Have applicant’s employees been trained and certified in fair housing laws? .................................. Yes No
18. Show the properties applicant has managed for the past twelve (12) months:
Property Type
Number of Units/
Square Feet/
Number of
Pools
Value of
Property
Vacancy
Rate
Gross
Commissions
and Fees
1-4 Family Residential
Units
Apartments
Units
Commercial/Industrial/
Warehouses
Sq. ft.
Condominiums
Units
Farms/Ranches
Units
Homeowners Association
Units
HUD—Housing and Urban
Development—Section 8
Units
Office Buildings
Sq. ft.
RV/Mobile Home Parks
Units
Senior Housing
Units
Shopping Centers
Sq. ft.
Student Housing
Units
Timeshare Association
Units
Vacation Properties
Units
Other:
Annual Commercial Receipts: ................................................................................................................ $
Annual Residential Receipts: .................................................................................................................. $
GLZ-SUPP-1g (6-13) Page 2 of 6
19. Services offered by applicant:
Accepting and disbursing rent? ................................................................................................................... Yes No
Addressing ordinary repair and maintenance? ............................................................................................ Yes No
Security services? ........................................................................................................................................ Yes No
Janitorial services for managed properties? ................................................................................................ Yes No
Services provided for lender in conjunction with foreclosed /REO properties?........................................... Yes No
Other—Describe:
20. Does applicant have payroll or subcontractor cost for any of the following exposures? ................ Yes No
Trade Payroll Subcontractor Cost
Certificates of Insurance
Required and on File
Carpentry
Yes No
Construction Development
Yes No
Electrical
Yes No
Handyperson
Yes No
Maintenance
Yes No
Landscaping
Yes No
Plumbing
Yes No
Security
Yes No
Snow Removal
Yes No
Any other Contractors*
Yes No
Any other Services*
Yes No
*If any other contractors or other services are performed, please explain:
21. Is there a written procedure in place for responding to tenants requests for repairs? ..................... Yes No
What is the response time for tenants requests for repairs?
Does applicant maintain service records of all repairs? .............................................................................. Yes No
How long are the records kept?
22. Provide information of activities other than property management:
Description
Gross Income
Last Twelve (12)
Months
Number of
Transactions
Projected Income
Next Twelve (12)
Months
Commercial Sales $
$
Mortgage Brokerage/Financial Arrangements $
$
Real Estate Appraisal Fees $
$
Residential Sales $
$
Other—Describe
$ $
Total Gross Income $
$
GLZ-SUPP-1g (6-13) Page 3 of 6
23. Does applicant manage any vacant land/lots? ....................................................................................... Yes No
If yes, number of: acres
lots
Is there any current or future development activity occurring? ........................................................... Yes No
Explain:
24. List Additional Interests and Certificate Recipients
Name and Address Interest
25. Does applicant have a professional liability insurance policy in force? ............................................. Yes No
26. Does the property owner require that they be named as an additional insured on applicant’s
policy? ........................................................................................................................................................
Yes No
27. Is the applicant named as an additional insured on the property owner’s policy? ........................... Yes No
28. DOES APPLICANT HAVE THE FOLLOWING? IF YES, ATTACH COPY.
Rental contract? ........................................................................................................................................ Yes No
Brochures? ................................................................................................................................................. Yes No
Send copy of Property Management Agreement with property owners.
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 to Oregon).
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 addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any in-
surer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a
felony of the third degree.
GLZ-SUPP-1g (6-13) Page 4 of 6
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 may be guilty of a criminal offense and subject to penalties under 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 AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for commercial insurance or a statement of claim for any commercial or per-
sonal insurance benefits containing any materially false information, or conceals for the purpose of misleading, infor-
mation concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly
makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, dam-
age or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance
company, 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 value of the subject motor vehicle or stated claim for each violation.
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 civil penalty not to exceed five thousand dollars
and the stated value of the claim for each such violation.
GLZ-SUPP-1g (6-13) Page 5 of 6
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 state-
ments are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying.
(Kansas: 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.)
CO-APPLICANT’S SIGNATURE: ________________________________________________ DATE:
PRODUCER’S SIGNATURE: ___________________________________________________ DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IOWA LICENSED AGENT:
NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT:
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.
GLZ-SUPP-1g (6-13) Page 6 of 6
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Real Estate Property Management Supplemental Application (RT Specialty)

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Completed 13 December 2020

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