Commercial Insurance Underwriters, Inc. A Surplus Lines Agency www.ciusgf.com 901 E. Saint Louis St. #205 Springfield, MO. 65806-2537

Condominium or Homeowners Association General Liability Application

ANSWER ALL QUESTIONS - IF THEY DO NOT APPLY, INDICATE "NOT APPLICABLE"

Applicant Is: Individual  Corporation   Partnership    Joint Venture   Limited Liability Company  Other 

Other Type: 

A.    Number of years in business?   

B.    Have all development and/or construction operations been completed?    No Yes

C.    Is the builder or developer a member of the board of directors for the association?    No Yes

D.    Is association membership voluntary?    No Yes

If yes:

How many association members?   

How many non-members are living within the boundaries of the association?   

E.    Number of units:   

F.    Number of stories:                Sprinkled?    No Yes

Fire Resistive?    No Yes

G.    Number of pools?   

1.    Number of diving boards, pool slides or diving platforms?      

2.    Any slides over 10ft. in height?    No Yes

3.    Are the pools fenced?    No Yes

4.    Are the rules posted?    No Yes

5.    Are gates self-closing and locking?    No Yes

6.    Any lifeguards?    No Yes

H.    Number of:

*    (If applicable, complete Dam Questionnaire GLS-113)

**  Is swimming allowed in the lakes?    No Yes

I.    Does the association have an airport:    No Yes

J.    Any waterworks/sewage treatment/disposal facilities?    No Yes

Describe in detail:

If yes, is it maintained and operated by insured?    No Yes

K.    Are there any garbage dumps or landfills?    No Yes

L.    Is the association responsible for maintenance of the roads?    No Yes

If yes, how many?   

M.    How many parks?   

Describe in detail:

How many trails?   

N.    Any horse trails or bike trails:    No Yes

If yes, how many miles of trails?   

Describe in detail:

O.    Any stables?    No Yes         Riding arenas?    No Yes

Any jumps?    No Yes         Saddle animals for hire?    No Yes

P.    Is this a master association which provides group common areas for individual associations?    No Yes

Q.    Does association include commercial and/or institutional members?    No Yes

R.    Any security guards on premises?    No Yes

If yes, how many?        Are they armed or unarmed?    Armed Unarmed

Does association directly employ guards?    No Yes

If outside security guard service, are certificates of insurance required?    No Yes

S.    Total number of employees?   

T.    Does applicant have Workers Compensation coverage in force?    No Yes

U.    Does applicant lease employees?    No Yes

V.    Any Special Events?    No Yes

W.    Any sponsored athletic teams?    No Yes

If yes, please explain:

X.    Any other exposures which the association is responsible for?    No Yes

Y.    Please attach any descriptive or advertising literature.   

Z.    Does applicant have other business ventures for which coverage is not requested?    No Yes

If yes, please explain and advise where insured:

Previous Insurer and Loss History:  Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give rise to claims for the prior three years.

Any prior losses due to mold?    No Yes

If yes, has mold been completely remediated?    No Yes

This application dos not bind the applicant nor the Company to complete the insurance, but it is agreed that the information 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.

FRAUD WARNING (APPLICABLE IN FLORIDA):

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

FRAUD WARNING (APPLICABLE IN MAINE):

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.

 FRAUD WARNING (APPLICABLE IN TENNESSEE 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. Penalties include imprisonment, fines, and denial of insurance benefits.

FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK:

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.

NAME AND TITLE:   

APPLICANT'S SIGNATURE:__________________________________________________ DATE:__________________

PRODUCER'S SIGNATURE:__________________________________________________ DATE:__________________

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.