Condo & Homeowner

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Commercial Insurance Underwriter

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

Condominium and Homeowner Association

Directors and Officers General Liability Application

(Claims Made Basis)

Applicant's Name		Agency Name
Address		Agent
		Address
Location
		Email
Web Site Address		Phone

Proposed Effective Date:	From	To
	12:01 A.M., Standard Time at the address of the Applicant

Applicant is:	Individual	Corporation	Partnership	Joint Venture
	Limited Liability Company		Other (Specify)

This application must be signed and dated, and not completed earlier than 60 days before proposed effective date.

Answer all questions. If a question is not applicable, state NOT APPLICABLE. If the answer to any question is none,

state NONE. If space is insufficient to answer any question fully, attach a separate sheet(s).

Limit of liability each policy year:

$300,000

$500,000

$1,000,000

Deductible desired ($1,000 minimum deductible):

Date of incorporation:

4.	List directors and officers below (use additional page if more than 10):

	Name	Director or Officer	Occupation	Months in residence
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

5.	Name and address of developer:

Number of units:

Average value:

Estimated market value of development:

Date Development was completed:

10.

Type of building:

Single family dwellings

Condominiums

Townhomes

Other:

11.

Percentage of commercial occupancy:

12.

Describe type of commercial occupancy:

13.

Number of units currently owned by developer:

14.

Date last unit completed and sold:

15.

Does the declaration, master deed or bylaws provide for indemnification of the directors and officers?

16.

Does developer/sponsor have any representation on the board of directors?

	If yes, explain:

17.

Date of annual meeting of association:

18.	Has any insurer canceled, declined, or nonrenewed directors and officers liability insurance of this association?
	(Not applicable in Missouri)

	If yes, give reason:

19.

Has applicant previously had a directors and officers liability insurance policy?

If yes, provide information below.

Company	Policy Number	Effective Dates	Claims Made or Occurrence

20.

Is the management of the association conducted by a management firm or agency?

	If yes, list name and address:

21.

Does any owner, director or officer of the association have a financial interest in or work for the management company?

	If yes, explain:

22.

Percentage of units rented or subleased on a short term or rental pool basis:

	If any, give details:

23.

Does the board have the power to condemn property?

24.

Does applicant have Workers' Compensation coverage in force?

25.

Does applicant lease employees?

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.

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.

No person proposed for this insurance is cognizant of any act, omission or error which he has

reason to suppose might afford valid grounds for any future claim such as would fall within the

scope of the proposed insurance except as follows (if none, indicate by "No exceptions"):

The undersigned authorized officer of the condominium/cooperative declares that to the best

of his knowledge and belief the statement set forth herein are true and complete, and knows

of no other information which relates to the consideration of this insurance.

I understand that this application is for the issuance of a policy that provides liability coverage

only for injuries that occur during the policy period and claims arising therefrom made during

the policy period.

The undersigned hereby authorizes the release of claim information from any prior insurer to the Company.

NAME OF ENTITY:_____________________________________________________________________________________

BY:___________________________________________________________________________________________________

TITLE:_________________________________________________________________________________________________

DATE:_________________________________________________________________________________________________

(Must be signed by Chairman of the Board or President)

AGENT NAME:__________________________________________ AGENT LICENSE NUMBER_______________________

(Applicable to Florida Agents Only.)

*Signing this form does 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. Application must be currently signed and dated to be considered for quotation.

NOTE: A copy of the association's two latest statements of conditions and a copy of the bylaws must accompany this proposal. No change in bylaws.

IMPORTANT NOTICE

As part of our underwriting procedures, 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.

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

Before You Submit To Us, Make Sure You Fill in the RED Areas. We Also Recommend Printing a Copy!!
TO COMPLETE YOUR APPLICATION, COMPLETE THESE TWO STEPS:
1. Please select your Personal Lines Account Executive:	2. Hit this Submit button.