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COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

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  • 77 check-boxes
  • 34 other fields

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File type: PDF

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C‐APP022‐0815 Page1of4
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION - HOMEOWNERS ASSOCIATIONS - 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:
PROHIBITED (check all that apply to your operations)
Adult foster care
Aluminum wiring
Assisted living
Condo conversions if original structure was not habitational use to begin with
Halfway houses, Homeless shelters
Heights of buildings are over 4 stories and not at least MNC construction, and 100% sprinklered
Marinas open to the public
Rehab centers
Saddle animals for hire
Structural renovations
SUBMIT
Occupancy rate is under 75% annually Occupancy is actually _____ %
Single Family Dwellings (SFD’s) if total exceeds 10
Student housing exceeds 25% Student housing is actually _____ %
Subsidized housing exceeds 25% Subsidized housing is actually _____ %
YEARS IN BUSINESS / EXPERIENCE
_____ Years in business as the ‘Named Insured’ indicated on this application
_____ Years’ experience in the operations indicated on this application - Attach resumes if available
Has applicant had an insurance policy cancelled or non-renewed in past 3 years? If yes, explain.
(Missouri Applicants - Do not answer this question)
Applicant in receivership
Bankruptcy (Chapter 7, 11 or 13) has been filed in past 5 years
C‐APP022‐0815 Page2of4
HOMEOWNERS ASSOCIATIONS - SUPPLEMENTAL APPLICATION
CONTRACTS
Written contracts are always used with third parties. If not, explain:
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 / OPERATIONS / CONTROLS
New construction or new conversions Units remain for sale
_____ Number of condominium or townhome units – owner occupied
_____ Number of condominium or townhome units – rented
_____ Number of condominium or townhome units – time share
_____ Number of single family dwellings – owner occupied
_____ Number of single family dwellings – rented
_____ Number of single family dwellings – time share
Carbon monoxide detectors provided in all living units
Elevators (if present) are properly inspected and have all code required safety features
Fire extinguished adequately placed in common areas and all are currently tagged
Security provided (must be unarmed) by third party who provides certificate confirming liability coverage
Smoke detectors are in all living units: Battery operated Hardwired
FACILITIES (check if applicable)
Bar/Tavern/Lounge
Beachfront
Boat Docks / Ramps / Slips If yes, total number of all: _______
Clubhouse – rented to residents only
Clubhouse – rented to non-residents
Convenience store
Fitness center
Hot tub
Lakes (must be posted no swimming) If yes, total acreage of all lakes: _____
Playground
Restaurant (complete Restaurant Supplemental Application)
Sauna / Steam Room
Swimming Pool(s) (check if applicable)
Number of swimming pools: _______
Depths marked, Life safety equipment placed in pool area, Rules posted
Competitions Diving Teams Swimming Instruction
Fenced completely with self-latching gate(s), if pool is outdoors
Life guards CPR trained Subcontracted out
Slides or diving boards Maximum height: _____ feet
C‐APP022‐0815 Page3of4
HOMEOWNERS ASSOCIATIONS - SUPPLEMENTAL APPLICATION
FACILITIES (continued) (check if applicable)
Swimming Pool(s) Number of swimming pools: _______
Depths marked, Life safety equipment placed in pool area, Rules posted
Competitions Diving Teams Swimming Instruction
Fenced completely with self-latching gate(s), if pool is outdoors
Life guards CPR trained Subcontracted out
Slides or diving boards Maximum height: _____ feet
Shuffleboard
Tennis courts
Volleyball courts
SUBCONTRACTORS
Uninsured subcontractors are not acceptable. Exceptions allowed in Texas subject to Company guidelines.
Describe type of work performed by subcontractors:
Risk Transfer – Subcontractors:
Additional Insured – Status granted to you on the subcontractor’s policy
Certificates of Insurance - Always obtained from a subcontractor prior to any work being done for you.
Limits of Liability - Subcontractors are required to carry limits equal or above your own
EMPLOYEES
Total Number of Employees (include leased employees): __________
Describe type of work performed by employees:
COVERAGE OPTIONS - LIABILITY (check if you would like an optional quote on any of the following)
Employee Benefit Liability – U058
Employment Practices Liability Insurance – U817 (Not available in AR, LA, MT, NM, NY, VT)
High Limits General Liability
Identity Recovery – i.e. Identity Theft – U651
Medical Expense Limit of $10,000 rather than $5,000
Stop Gap Liability – U066
COVERAGE OPTIONS - PROPERTY (check if you would like an optional quote on any of the following)
Building Ordinance or Law (Increased Cost of Construction) – U750
Equipment Breakdown – U522 & U523
Property Coverage Enhancement:
Bronze – U777C Silver – U777B or Gold – U777A
Signs (Outdoor) – CP1440
Water Back Up and Sump Overflow – U548
C‐APP022‐0815 Page4of4
HOMEOWNERS ASSOCIATIONS - 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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COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

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Completed 17 July 2021

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