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Western World Insurance Company Tudor Insurance Company Stratford (Risk Placement Services, Inc.)

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Page 1 of 2 A63 (10/05)
Application For Apartment/Condo
1. Business Name Phone #
Street address
City State Zip
Applicant’s Web Site Address
2. Year Built No. of Buildings No. of Stories
No. of Units % Units Occupied If condo, % owner occupied
3. Any timesharing? Yes No
4. Construction Roof Wiring
(If aluminum wiring, verify all outlets have been pigtailed and checked by a licensed electrical contractor within
past 5 years?) Yes No*
5. Type of heat/smoke detectors:
Hard-wired Battery Checked every Month(s)
6. Detectors in every unit? Yes No*
7. If apartments/condo are over 10 years old, fully describe all updates:
8. Condition of Property: Good Average Poor*
9. Surrounding Area:
Improving Stable Declining
10. Any Elevators?
Yes No Maintenance Contract? Yes No
How often maintained?
11. Are certificates of insurance obtained from elevator contractor? Yes No
Limits:
12. Pool Information: # of Pools Depth Markers? Yes No
# of Diving Boards Height: (If over 1 meter, refer)
# of Slides Height:
Pool Fenced? Yes No Fence Height?
Self-closing and self-latching gate(s)? Yes No*
Self-closing and self-latching features of gate(s) in proper
working condition?
Yes No*
How often are gates and fences checked?
Overhangs/Buildings less than 10 feet from pool?
Yes No
Rules posted? Yes No
Non-slip surface around pool?
Yes No
Other safety equipment:
Lifeguard(s) on duty when pool is open?
Yes No
* Must refer to company for approv
al.
Member Companies of Western World Insurance Group
Western World Insurance Company
Tudor Insurance Company
Stratford Insurance Company
Page 2 of 2 A63 (10/05)
13. If over 2 stories: Open or enclosed stairways? Open Enclosed
No. of exits 100% Sprinkled
Fire doors and panic hardware?
Windows protected for children? Please describe:
14. Sliding glass doors equipped with additional locks? Yes No
15. Doors equipped with dead bolts?
Yes No* Peep holes? Yes No*
16. Height of balcony railing Distance between bars on balconies Stair rails
(MUST ALL MEET CURRENT BUILDING CODE.)
17. Any guards who are employed?
Yes No
18. Independent contractors for security?
Yes No
Certificates of Insurance Required?
Yes No* Limits
19. Any armed guards? Yes* No Hold harmless agreements in your favor? Yes No
20. Percent of units with subsidies or government funding (HUD, etc.) (If over 20%, refer)
21. Percent rented to: Students Elderly (Refer if over 25% students)
22. Describe recreation facilities/amenities (i.e. tanning equipment, weight rooms, etc.)
23. Any remodeling/renovation anticipated within policy period? If yes, please provide complete details.
24. Details of claims/loss history for past three years.
25.
LIMITS OF INSURANCE REQUESTED:
General Aggregate Limit (Other than Products-Completed Operations) $
Products-Completed Operations Aggregate Limit $
Personal and Advertising Injury Limit $ any one person or
organization
Each Occurrence Limit $
Damage to Premises Rented to You (up to $50,000 limit available) $ any one premise
Medical Expense Limit (up to $5,000 limit available) $ any one person
Each Professional Incident Limit (if applicable) $
26.
Effective Dates Desired: From To
Applicant’s Signature:
Date:
(Required)
* Must refer to company for approval.
Title:
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Completed 30 July 2020

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