Apartments & Tenant Occupied Dwellings EZ RATE Liability Program 1500 University Drive, Suite 212 Coral Springs, Florida 33071 Phone (954) 341-8331 Fax (954) 345-7620 DATE:
FLORIDA Apartment Buildings - All Territories A Rated - Surplus Lines Carrier
December 10, 2010
Commercial General Liability Coverage CG0001 $2,000,000 $INCLUDED $1,000,000 $1,000,000 $100,000 $5,000
General Aggregate Limit Products - Completed Operations Aggregate Personal & Advertising Injury Limit Each Occurrence Limit Fire Damage Limit Deductible: $500 BI/PD Dwellings Medical Expense Limit Deductible: $500 BI/PD Apartments
Minimum Premiums Applicable - see below PREMIUM BASIS
TENANT OCCUPIED DWELLINGS & APARTMENTS RAPID-RATER
# of Units and/or Pools
Commercial General Liability Coverage - Limit $2,000,000 / $1,000,000
EACH UNIT
CLASS CODE
DESCRIPTION
PREMIUM
63010
Dwellings One-Family (Lessors Risk Only)
63011
Dwellings Two-Family (Lessors Risk Only)
63012
Dwellings Three-Family (Lessors Risk Only)
63014
Dwellings Four-Family (Lessors Risk Only)
60010
Apartment Buildings
48925
Swimming Pools
$0 $0 $0 $0 $0 $0
Pools must be rated in conjunction with the above classifications CG2018 Additional Insured - Mortgagee (No Charge) All properties must comply with building codes PREMIUM (subject to $500 MP) Surplus Lines Tax + Service Office Fee + FHCF Fee = Policy Fee $35.00 + Inspection Fee $75.00 = TOTAL IMPORTANT: Policy Minimum Premiums (Annual): Dwellings - $1,000,000 limit - $500 Apartments - $1,000,000 limit - $500
THANK YOU FOR YOUR BUSINESS!
$0 6.10% $6.71 $110.00 $116.71
ACORD
TM
COMMERICAL INSURANCE APPLICATION
PHONE
PRODUCER
DATE
APPLICANT INFORMATION SECTION CARRIER
(A/C, No, Ext): FAX (A/C, No,):
UNDERWRITER OFF.
UNDERWRITER
NAIC CODE:
POLICY NUMBER
POLICIES OR PROGRAM REQUESTED
INDICATE SECTIONS ATTACHED
SUB CODE:
CODE:
AGENCY CUSTOMER ID
STATUS OF TRANSACTION QUOTE
EQUIPMENT FLOATER
GARAGE AND DEALERS
PROPERTY
INSTALLATION/BUILDERS RISK
VEHICLE SCHEDULE
GLASS AND SIGN ACCOUNTS RECEIVABLE/ VALUABLE PAPERS
ELECTRONIC DATA PROC COMMERCIAL GENERAL LIABILITY
BOILER & MACHINERY
CRIME/MISCELLANEOUS CRIME TRANSPORTATION/ MOTOR TRUCK CARGO
BUSINESS AUTO
UMBRELLA
WORKERS COMPENSATION
TRUCKERS/MOTOR CARRIER
PACKAGE POLICY INFORMATION RENEW ENTER THIS INFORMATION WHEN COMMON DATES AND TERMS APPLY TO SEVERAL LINES, OR FOR MONOLINE POLICIES.
ISSUE POLICY
PROPOSED EFF DATE
BOUND (Give Date and/or Attach Copy): DATE TIME CHANGE
PROPOSED EXP DATE
CANCEL
PAYMENT PLAN
BILLING PLAN
AUDIT
DIRECT BILL
AM PM
AGENCY BILL
APPLICANT INFORMATION FEIN OR SOC SEC # (of First Named Insured): PHONE
NAME (First Named Insured & Other Named Insureds)
MAILING ADDRESS INCL ZIP+4 (of First Named Insured)
(A/C, No, Ext): INTERNET ADDRESS
INDIVIDUAL
CORPORATION
PARTNERSHIP
JOINT VENTURE PHONE (A/C, No, Ext):
INSPECTION CONTACT
NOT FOR PROFIT ORG
SUBCHAPTER "S" CORPORATION LIMITED CORPORATION
CR BUREAU NAME
YEAR BUS STARTED
ID NUMBER
ACCOUNTING RECORDS CONTACT
PHONE
(A/C, No, Ext):
PREMISES INFORMATION LOC #
BLD #
STREET, CITY, COUNTY, STATE, ZIP+4
CITY LIMITS
INTEREST
INSIDE
OWNER
OUTSIDE
TENANT
INSIDE
OWNER
OUTSIDE
TENANT
INSIDE
OWNER
OUTSIDE
TENANT
YR BUILT
PART OCCUPIED
NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS BY PREMISE(S)
GENERAL INFORMATION YES NO
EXPLAIN ALL "YES" RESPONSES
1. IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY OR DOES
YES
NO
MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING? 8. DURING THE LAST FIVE YEARS (TEN IN RI), HAS ANY APPLICANT BEEN CONVICTED OF ANY DEGREE OF THE CRIME OF ARSON? In RI, this question must be answered by any applicant for property insurance. Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment).
2. IS A FORMAL SAFETY PROGRAM IN OPERATION? 3. ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS? 4. ANY CATASTROPHE EXPOSURE? 5. ANY OTHER INSURANCE WITH THIS COMPANY OR BEING SUBMITTED? 6. ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE PRIOR 3 YEARS? NOT APPLICABLE IN MO REMARKS/PROCESSING INSTRUCTIONS
EXPLAIN ALL "YES" RESPONSES
7. ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR
THE APPLICANT HAVE ANY SUBSIDIARIES?
9. ANY UNCORRECTED FIRE CODE VIOLATIONS? 10. ANY BANKRUPTCIES, TAX OR CREDIT LIENS AGAINST THE APPLICANT IN THE PAST 5 YEARS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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 THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (NOT APPLICABLE IN CO, HI, NE, OH, OK, OR, VT; IN DC, LA, ME AND VA, INSURANCE BENEFITS MAY ALSO BE DENIED) APPLICANT'S SIGNATURE
ACORD 125 (2000/08)
PRODUCER'S SIGNATURE
PLEASE COMPLETE REVERSE SIDE
© ACORD CORPORATION 1993
PRIOR CARRIER INFORMATION CATEGORY
LINE
CARRIER
POLICY NUMBER CLAIMS MADE
POLICY TYPE
OCCURRENCE
CLAIMS MADE
OCCURRENCE
CLAIMS MADE
OCCURRENCE
CLAIMS MADE
CLAIMS MADE
OCCURRENCE
OCCURRENCE
RETRO DATE EFF-EXP DATE G E
GENERAL AGGREGATE
N
PRODUCTS COMP OP
C E O R
AGGREGATE
MA M L
PERSONAL & ADV INJ
E L
R I
C A
I B A I L L
I T Y
EACH OCCURRENCE L
FIRE DAMAGE
I
M
I MEDICAL EXPENSE T S BODILY OCCURRENCE INJURY AGGREGATE PROPERTY OCCURRENCE
DAMAGE AGGREGATE COMBINED SINGLE LIMIT
MODIFICATION FACTOR TOTAL PREMIUM CARRIER
POLICY NUMBER
A U L T I O A
M
B
O I
POLICY TYPE EFF-EXP DATE
COMBINED SINGLE LIMIT
B L
BODILY INJURY
I I
L T E Y
EA PERSON
EA ACCIDENT
PROPERTY DAMAGE
MODIFICATION FACTOR TOTAL PREMIUM CARRIER
POLICY NUMBER P
R
O P E
POLICY TYPE EFF-EXP DATE
R
BUILDING
AMT
T Y
PERS PROP
AMT
MODIFICATION FACTOR TOTAL PREMIUM CARRIER
POLICY NUMBER POLICY TYPE EFF-EXP DATE
LIMIT MODIFICATION FACTOR TOTAL PREMIUM
LOSS HISTORY ENTER ALL CLAIMS OR LOSSES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED) OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS FOR THE PRIOR 5 YEAR (3 YEARS IN KS & NY)
DATE OF OCCURRENCE
LINE
TYPE/DESCRIPTION OF OCCURRENCE OR CLAIM
DATE OF CLAIM
AMOUNT PAID
CHK HERE IF NONE
AMOUNT RESERVED
SEE ATTACHED LOSS SUMMARY
CLAIM STATUS OPEN
CLOSED OPEN
CLOSED
REMARKS
NOTE: FIDELITY REQUIRES A FIVE YEAR LOSS HISTORY
NOTICE OF INSURANCE INFORMATION PRACTICES
PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT POLICY RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTION ON HOW TO SUBMIT A REQUEST TO US.
ACORD 125 (2000/08)
RESET
This is a FILL OUT and Print form! Type in the spaces you would write in. Click on the check boxes and buttons. This fillable form function provided by ConsumerArts.com
COMMERCIAL GENERAL LIABILITY SECTION PHONE (A/C, No, Ext): FAX (A/C, No):
AGENCY
DATE (MM/DD/YYYY)
APPLICANT (First Named Insured) EFFECTIVE DATE
EXPIRATION DATE
PAYMENT PLAN
DIRECT BILL
AUDIT
AGENCY BILL
CODE: AGENCY CUSTOMER ID:
FOR COMPANY USE ONLY
SUB CODE:
COVERAGES
LIMITS
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE
OCCURRENCE
OWNER’S & CONTRACTOR’S PROTECTIVE
DEDUCTIBLES
PROPERTY DAMAGE
$
BODILY INJURY
$
PER CLAIM
$
PER OCCURRENCE
GENERAL AGGREGATE
$
PRODUCTS & COMPLETED OPERATIONS AGGREGATE
$
PERSONAL & ADVERTISING INJURY
$
EACH OCCURRENCE
$
DAMAGE TO RENTED PREMISES (each occurrence)
$
MEDICAL EXPENSE (Any one person)
$
EMPLOYEE BENEFITS
$
PREMIUMS PREMISES/OPERATIONS
PRODUCTS
OTHER
TOTAL
$0.00
OTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS (For hired/non-owned auto coverages attach the applicable state Business Auto Section, ACORD 137)
SCHEDULE OF HAZARDS LOCATION #
CLASSIFICATION
RATING AND PREMIUM BASIS
(S) GROSS SALES - PER $1,000/SALES
CLASS CODE
PREMIUM BASIS
(P) PAYROLL - PER $1,000/PAY (A) AREA - PER 1,000/SQ FT
EXPOSURE
RATE
TERR
PREM/OPS
(C) TOTAL COST - PER $1,000/COST (M) ADMISSIONS - PER 1,000/ADM
CLAIMS MADE (Explain all "Yes" responses)
PREMIUM
PRODUCTS
PREM/OPS
PRODUCTS
(U) UNIT - PER UNIT (T) OTHER
EMPLOYEE BENEFITS LIABILITY
1. PROPOSED RETROACTIVE DATE:
1. DEDUCTIBLE PER CLAIM:
2. ENTRY DATE INTO UNINTERRUPTED CLAIMS MADE COV: 3. HAS ANY PRODUCT, WORK, ACCIDENT, OR LOCATION BEEN EXCLUDED, UNINSURED OR SELF-INSURED FROM ANY PREVIOUS COVERAGE?
2. NUMBER OF EMPLOYEES: YES NO
$
3. NUMBER OF EMPLOYEES COVERED BY EMPLOYEE BENEFITS PLANS: 4. RETROACTIVE DATE:
4. WAS TAIL COVERAGE PURCHASED UNDER ANY PREVIOUS POLICY? REMARKS
ACORD 126 (2004/03)
REMARKS
PLEASE COMPLETE REVERSE SIDE
© ACORD CORPORATION 1993
CONTRACTORS EXPLAIN ALL "YES" RESPONSES (For past or present operations)
YES NO
EXPLAIN ALL "YES" RESPONSES (For past or present operations)
YES
1. DOES APPLICANT DRAW PLANS, DESIGNS, OR SPECIFICATIONS FOR OTHERS?
4. DO YOUR SUBCONTRACTORS CARRY COVERAGES OR LIMITS LESS THAN YOURS?
2. DO ANY OPERATIONS INCLUDE BLASTING OR UTILIZE OR STORE EXPLOSIVE MATERIAL?
5. ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT PROVIDING YOU WITH A CERTIFICATE OF INSURANCE?
3. DO ANY OPERATIONS INCLUDE EXCAVATION, TUNNELING, UNDERGROUND WORK OR EARTH MOVING?
6. DOES APPLICANT LEASE EQUIPMENT TO OTHERS WITH OR WITHOUT OPERATORS?
$ PAID TO SUBCONTRACTORS:
REMARKS/DESCRIBE THE TYPE OF WORK SUBCONTRACTED
% OF WORK SUBCONTRACTED:
# FULLTIME STAFF:
NO
# PARTTIME STAFF:
PRODUCTS/COMPLETED OPERATIONS PRODUCTS
ANNUAL GROSS SALES
TIME IN MARKET
# OF UNITS
EXPLAIN ALL "YES" RESPONSES (For any past or present product or operation)
YES NO
EXPECTED LIFE
INTENDED USE
PRINCIPAL COMPONENTS
EXPLAIN ALL "YES" RESPONSES (For any past or present product or operation)
1. DOES APPLICANT INSTALL, SERVICE OR DEMONSTRATE PRODUCTS?
6. PRODUCTS RECALLED, DISCONTINUED, CHANGED?
2. FOREIGN PRODUCTS SOLD, DISTRIBUTED, USED AS COMPONENTS?
7. PRODUCTS OF OTHERS SOLD OR RE-PACKAGED UNDER APPLICANT LABEL?
3. RESEARCH AND DEVELOPMENT CONDUCTED OR NEW PRODUCTS PLANNED?
YES
NO
YES
NO
8. PRODUCTS UNDER LABEL OF OTHERS?
4. GUARANTEES, WARRANTIES, HOLD HARMLESS AGREEMENTS?
9. VENDORS COVERAGE REQUIRED?
5. PRODUCTS RELATED TO AIRCRAFT/SPACE INDUSTRY?
10. DOES ANY NAMED INSURED SELL TO OTHER NAMED INSUREDS?
PLEASE ATTACH LITERATURE, BROCHURES, LABELS, WARNINGS, ETC
ADDITIONAL INTEREST/CERTIFICATE RECIPIENT INTEREST
RANK:
NAME AND ADDRESS
ACORD 45 attached for additional names
REFERENCE #:
CERTIFICATE REQUIRED
INTEREST IN ITEM NUMBER
ADDITIONAL INSURED
LOCATION:
BUILDING:
LOSS PAYEE
VEHICLE:
BOAT:
MORTGAGEE
SCHEDULED ITEM NUMBER:
LIENHOLDER
OTHER
EMPLOYEE AS LESSOR ITEM DESCRIPTION:
GENERAL INFORMATION EXPLAIN ALL "YES" RESPONSES (For all past or present operations)
1. ANY MEDICAL FACILITIES PROVIDED OR MEDICAL PROFESSIONALS EMPLOYED OR CONTRACTED? 2. ANY EXPOSURE TO RADIOACTIVE/NUCLEAR MATERIALS? 3. DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc) 4. ANY OPERATIONS SOLD, ACQUIRED, OR DISCONTINUED IN LAST 5 YEARS? 5. MACHINERY OR EQUIPMENT LOANED OR RENTED TO OTHERS? 6. ANY WATERCRAFT, DOCKS, FLOATS OWNED, HIRED OR LEASED? 7. ANY PARKING FACILITIES OWNED/RENTED?
EXPLAIN ALL "YES" RESPONSES (For all past or present operations)
12. ANY STRUCTURAL ALTERATIONS CONTEMPLATED? 13. ANY DEMOLITION EXPOSURE CONTEMPLATED? 14. HAS APPLICANT BEEN ACTIVE IN OR IS CURRENTLY ACTIVE IN JOINT VENTURES? 15. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS? 16. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS OR SUBSIDIARIES? 17. ARE DAY CARE FACILITIES OPERATED OR CONTROLLED? 18. HAVE ANY CRIMES OCCURRED OR BEEN ATTEMPTED ON YOUR PREMISES WITHIN THE LAST THREE YEARS? 19. IS THERE A FORMAL, WRITTEN SAFETY AND SECURITY POLICY IN EFFECT?
8. IS A FEE CHARGED FOR PARKING? 9. RECREATION FACILITIES PROVIDED? 10. IS THERE A SWIMMING POOL ON THE PREMISES? 11. SPORTING OR SOCIAL EVENTS SPONSORED?
YES NO
20. DOES THE BUSINESSES’ PROMOTIONAL LITERATURE MAKE ANY REPRESENTATIONS ABOUT THE SAFETY OR SECURITY OF THE PREMISES?
REMARKS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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 THE PERSON TO CRIMINAL AND [NY:SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, HI, NE, OH, OK, OR or VT; in DC, LA, ME, TN and VA, insurance benefits may also be denied).
ACORD 126 (2004/03)
ATTACH TO APPLICANT INFORMATION SECTION
IMPORTANT INFORMATION POLICYHOLDER DISCLOSURE NOTICE OF INSURANCE COVERAGE FOR ACTS OF TERRORISM You are hereby notified that under the Terrorism Risk Insurance Act of 2002, effective November 26, 2002, you have a right to purchase insurance coverage for losses arising out of acts of terrorism, as defined in Section 102(1) of the Act, subject to all applicable policy provisions. The term “act of terrorism” means any act that is certified by the Secretary of the Treasury, in concurrence with the Secretary of State, and the Attorney General of the United States—to be an act of terrorism; to be a violent act or an act that is dangerous to human life, property; or infrastructure; to have resulted in damage within the United States, or outside the United States in the case of an air carrier or vessel or the premises of a United States mission; and to have been committed by an individual or individuals acting on behalf of any foreign person or foreign interest, as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. You should know that coverage provided by this policy for losses caused by certified acts of terrorism is partially reimbursed by the United States under a formula established by federal law. Under this formula, the United States pays 90% of covered terrorism losses exceeding the statutorily established deductible paid by the insurance company providing the coverage. The premium charged for this coverage is provided below and does not include any charges for the portion of loss covered by the federal government under the Act.
PLEASE SELECT ONE OF THE FOLLOWING TO EITHER ACCEPT OR REJECT TERRORISM INSURANCE COVERAGE: I hereby elect to purchase coverage for losses arising out of certified acts of terrorism, as defined in the Act and subject to all applicable policy provisions, for a premium of $_________ plus any applicable tax which may apply , for the period of _________ to _________. You should know that your policy does not provide coverage for acts of terrorism that are not certified by the Secretary of the Treasury. I hereby reject coverage for losses arising out of certified acts of terrorism, as defined in the Act. I understand that losses arising out of terrorism will be excluded
Type or print Policyholder/Applicant Name: Policyholder/Applicant Signature: Policyholder/Applicant’s Title: Policy Number: Date:
Please return the original form to us through your agent. We recommend that you keep a copy of this notice for your records. MUS 01 01 TRIA 1207
STATEMENT OF DILIGENT EFFORT
Producing Agent_____________________________________ SSN____________________________________ Name of Agency_____________________________________________________________________________ Has sought to obtain: Type of Coverage______________________________________________________ for Named Insured _____________________________________________________from the following authorized insurers currently writing this type of coverage: (1)
Authorized Insurer _________________________________ Person Contacted _____________________ Telephone Number_____________________ Date of Contact __________________________________
The reason(s) for declination by the insurer was (were) as follows: __________________________________________________________________________________________ (2)
Authorized Insurer __________________________________ Person Contacted ____________________ Telephone Number_____________________ Date of Contact ___________________________________
The reason(s) for declination by the insurer was (were) as follows: __________________________________________________________________________________________ (3)
Authorized Insurer _________________________________Person Contacted ______________________ Telephone Number _____________________
Date of Contact _________________________________
The reason(s) for declination by the insurer was (were) as follows: ___________________________________________________________________________________________
____________________________________ Signature of Producing Agent
________________________________________________ Printed or Typed Name of Producing Agent
Document Verified by Surplus Lines Agent: Yes ___ No ____ Date Verified: _________________
DI4-1153 7/94
