III. ADDITIONAL PROPERTY INFORMATION
If you own the building and it is older than 10 years old, please complete the following:
Age of roof __________yrs. Plumbing updated (yr) _________ Electrical updated (yr) __________ Heating updated (yr) _________
Roof type: q Flat q Wood shake q Shingle q Metal q Tile q Slate q Other ____________________
Plumbing type:q PVC q Copper q Lead q Galvanized q Other _____________________
What type of burglar alarm is on the premises? q Central station q Local q None
How many years has the applicant been at the current location? _______
IV. ELIGIBILITY CRITERIA
1. No bankruptcies, tax or credit liens against the applicant in the last five years q True q False
2. Coverage has not been cancelled or non-renewed in the last three years (not applicable in Missouri) q True q False
If “False,” advise reason _________________________________________________________________________________________________
Property
1. For any building built prior to 1978, 100% of the electric wiring is on functioning and
operating circuit breakers q N/A q True q False
2. For any building built prior to 1978, there is no aluminum wiring or knob and tube wiring q N/A q True q False
3. Functioning and operational fire extinguishers available q True q False
4. Functioning and operational smoke detectors in all units and/or occupancies q True q False
General Liability
1. No more than $3,000,000 in annual gross receipts q True q False
V. ADDITIONAL APPLICANT INFORMATION
Form of business: q Individual q Corporation q Partnership q LLC q Other ____________________________
What year did the business start?
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: ___________________________________
Audit contact name: ____________________________________________ Telephone/E-mail address: ___________________________________
Virginia Notice: 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.
Minnesota Notice: The clause “and/or authorization or agreement to bind the insurance.” is replaced with “Authorization or agreement to bind
the insurance may be withdrawn or modified 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.”
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.
Florida Fraud Statement: 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.
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.
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 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.
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.
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.
MMPA 3/11 - United States Liability Insurance Group
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