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ABOUT
TERMS & CONDITIONS
PANEL ATTORNEYS
MEDIA ARTICLES
REQUEST PREMIUM QUOTE
CONTACT
Printable Application
Insurance Application
Please fill out form below and submit. *Required Fields
Applicant Information
Agency Name
Name of Individual Completing This Application
*
Phone #
*
Email Address
*
Producer Name
Producer License #
Account Information
Requested Effective Date
*
FEIN Number
*
Name of Insured (Name of Association)
*
Contact Person at Location
*
Title
Phone Number
*
Email Address
Mailing Address
City
State
Zip
Has Insured Been Involved Any Lawsuits or Legal Claims in the Past 5 years?
*
Yes
No
Have any complaints been filed against insured with any state/county/city or governmental agency?
*
Yes
No
Additional Insureds to be listed on the policy
Insured 1
Insured 2
Insured 3
Insured 4
Required Underlying Insurance Information
General Liability Carrier
Effective Date
Limits
Directors & Officers Liability Carrier
Effective Date
Limits
Property Carrier
Effective Date
Limits
Wind Carrier ( if different than property carrier )
Effective Date
Limits
Premisis Information
Total Unit Count For all Risk Types Except HOA:
*
Total HOA Homes
*
*Condominium Association & Co-Op (# of Units) / Homeowners Association (# of Homes)
* Apartment Complex (# of Apartments) / Hotel (# of Rooms) / Commercial Office Structure (# of Tenents)
Please complete the following for each physical location.
You may also attach a chord form 139 if you have additional locations. Please be sure to put risk type under class code.
Location 1
Risk Type
Condo
HOA
Co-Op
Apartment
Hotel/Motel
Commercial Structure
Address
City
State
Zip
Location 2
Risk Type
Condo
HOA
Co-Op
Apartment
Hotel/Motel
Commercial Structure
Address
City
State
Zip
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF LCAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY ( IN FLORIDA, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
The undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true and complete and may be relied upon by Company in quoting and issuing the policy. If any of the information is this Application changes prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the quote or binder.
Check here if understand and agree.
*
I Agree
Name
*
Date Signed
*
Please Sign Below
*
I Have Reviewed the Application and All Information is True and Accurate.
Submit Application
