Habitational Application

PRINTABLE APPLICATION

HABITATIONAL APPLICATION

Applicant's Name:
Mailing Address:
City State Zip
Phone: Fax:

PROPOSED EFFECTIVE DATE:
From To
12:01 A.M. Standard Time at the address of the Applicant
Email Address:

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

LIMITS OF LIABILITY REQUESTED

General Aggregate

Products & Completed Operations Aggregate

Personal & Advertising Injury

Each Occurrence

Fire Damage (any one fire)

Medical Expense (any one person)

Other Coverages, Restrictions and/or Endorsements
	Deductible

PROPERTY LOCATIONS:
#	Location Name	Street Address	City	County	State	Zip Code
1.
2.
3.
4.
5.
6.

B. RENOVATION/MOST RECENT UPDATE
Year & Type of Update	Loc. #1	Loc. #2	Loc. #3	Loc. #4	Loc. #5	Loc. #6
Roof
Plumbing
Paint
Sidewalks
Patio balconies/railings
Parking areas
Currently renovating?	Yes No	Yes No	Yes No	Yes No	Yes No	Yes No
Cost/type of renovation
Certificates for subcontractors on file?	Yes No	Yes No	Yes No	Yes No	Yes No	Yes No

C. SWIMMING POOL(S)    Loc. #s
Diving Boards? Yes No    If yes, height:
Slides? Yes No
Underwater lighting? Yes No
Steps into shallow end with handrails? Yes No
Ladder at deep end with handrails? Yes No
1. Is the pool area completely surrounded by building walls or fence?   Yes No   If yes, height of fence:
2. Are gates or doors opening into the pool area equipped with a self-closing and self-latching device?   Yes No
3. Are the depth markings clearly shown? Yes No
4. Are warning signs and rules posted and clearly visible? Yes No   Provide wording or photo.
5. Is rescue equipment, including a ring buoy and 12-foot pole or shepherd's hook, available poolside? Yes No
6. Is pool maintained by applicant or outside contractor? Applicant   Outside Contractor
     If outside contractor, are certificates of insurance on file?   Yes No
7. Are lifeguards provided by applicant or by outside pool management company? Applicant Pool Management Co.
     If outside, are certificates of insurance on file?   Yes No

D. MAINTENANCE
1. Is janitorial, lawn care, or snow removal, performed by outside contractor or applicant's employee?
     Contractor Employee
    If outside contractor, are certificates on file? Yes No
    Is the applicant named as additional insured on their policy? Yes No
2. Who is responsible for upkeep of sidewalks and driveways?

E. FIRE PROTECTION
1. Sprinklered? Yes No    All units? Yes No      Common areas only? Yes No
2. Smoke detectors in each unit? Yes No     Hardwire  OR   Battery    How often checked?
3. Fire extinguishers? Yes No    In common areas? Yes No    In each unit? Yes No
4. # of units per fire division?
5. Does aluminum wiring exist in any unit? Yes No

F. SECURITY - Completion of Section F. SECURITY not required for dwelling or boarding/rooming house occupancies.
Is security provided? Yes No     If yes, what type? Patrol Gated Access    Alarm Systems in each Unit
1. If patrol, please answer the following questions:
     a. Armed     Unarmed
     b. Are the guards employees of the management or independent contractors? Employees   Independent contractors
         If independent contractors, are certificates of insurance required? Yes No
         Is the applicant named as additional insured on their policy?   Yes No
     c. Is the security 24 hours?    Yes No
     d. What are the guards responsible for? Residents' safety     Complex and amenities
2. If gated, please answer the following questions:
     a. Is the entire apartment complex gated?    Yes No
     b. How is access obtained? Guard at gate     Card     Security code
     c. Who is given access?
     d. If the gate is card or security code access, how often is maintenance done on the gate?
         What procedure is in place if gate is not working?
3. If alarm systems are provided, please provide answers to the following questions:
     a. Are alarms systems in every unit? Yes   No
     b. Are the residents shown how to operate the alarm systems? Yes   No
     c. Who monitors the alarms?
4. Do the residents' doors or windows contain any of the following?
     Viewing windows in front doors       Lock pins for window and sliding glass doors
     Window locks/bars                             Dead bolts
5. Master keys and locks:
     a. How does management handle the monitoring of master keys?
     b. How are locks handled upon vacancy of residents? Re-keyed     Changed completely
6. Criminal incidents:
     a. Does management advise residents of all criminal activity that has taken place upon the properties? Yes   No
         How is this done?
    b. Is this information provided to prospective renters if requested? Yes   No

G. OTHER RECREATIONAL EXPOSURES
Number of:	Playground(s)	Tennis court(s)	Racquetball court(s)	Basketball court(s)
	Volleyball court(s)	Baseball field(s)	Acres of lakes/ponds	Beaches
	Miles of bike trails	Sq. ft. of clubhouse	Spa/gym(s)	Boat slip(s)
	Other:

Are these available to nonresidents for a fee? Yes No Annual receipts?

H. During the past three years, has any company canceled, declined, or refused similar insurance to the applicant?
Yes No If yes, explain:

PRIOR CARRIER INFORMATION
	Year:	Year:	Year:	Year:	Year:
Carrier
Policy Number
Total Premium	$	$	$	$	$

LOSS HISTORY - FIVE YEAR PERIOD
Date of Loss	Description of Loss	Amount Paid	Amount Reserved	Claim Status (Open or Closed)
		$	$
		$	$
		$	$
		$	$
		$	$

Application Completed By: Date:
Name and Phone Number of Individual to contact for Inspection/Audit: