HARTAN REAL ESTATE PROGRAM SUPPLEMENTAL APPLICATION

In order to obtain a quote, ALL questions must be answered in the corresponding sections that apply to this insured. Incomplete submissions will be declined.

AGENT / BROKER INFORMATION
  Brokerage/Agency Name
  Address
  City
  Country
  State
  Zip Code
  Phone #
  Fax #
  Contact Person
  E-mail Address
APPLICANT INFORMATION
  Company Name
  Address
  City
  Country
  State
  Zip Code
  Web Site URL
APPLICANT'S OPERATION
  Description of Applicant’s operations
  Additional Named Insureds
  Does the Applicant have any subsidiary companies where operations are different than the Applicant’s? Yes No
  Subsidiary Name
  Description of Subsidiary’s Operations
PROPOSED POLICY INFORMATION
  Effective Date
  Expiration Date
  Lead Umbrella Limit Requested
EXPIRING INSURANCE INFORMATION
  New Business submission to AIG,
Expiring Lead Umbrella Carrier
  If New Business submission, Expiring Lead Umbrella Limits
  Lead Umbrella Limit Requested
  Expiring Annual Umbrella Premium $
  If Renewal to AIG, Expiring Certificate No
SUBMISSION EXPOSURE SUMMARY
  Total # of Locations
  Total Sq Ft
  Total Commercial Sq Ft Excluding Habitational
  Total # of Rental Units
  Total # of Coop/Condo Units
  Total # of Hotel Rooms
  Total Acres of Vacant Land
  Total # of Owned Autos
PROGRAM / INDUSTRY QUESTIONS
1. Are all locations currently in compliance with all property statutes, local ordinances and building codes? Yes No
  If no, please explain
2. Does the applicant have any of the following exposures at any location?
a. Subsidized Housing: Yes No
  If yes, any locations at which more than 15% of the units are subsidized? Yes No
b. Assisted Living Facility(ies) Yes No
c. Senior Housing Yes No
d. Student Housing Yes No
e. any Marina Yes No
f. Nightclubs Yes No
3. Does the applicant have any armed security personnel? Yes No
a. If yes, is the armed guard(s) an employee of the applicant? Yes No
b. If contracted, does the applicant require that the security service retain at least $1 million of liability? coverage? Yes No
4. Are all buildings at least 70% occupied? Yes No
5. Are there any habitational units/commercial space in buildings not owned/managed by the applicant? Yes No
FIRE, LIFE, SAFETY INFORMATION
1. Do all units contain hard wired or regularly maintained battery powered smoke detectors?
 Yes No
2. Are there at least two means of egress per floor at all locations? Yes No
a. If NO, please explain:
3. Are all buildings over 9 stories either 1) Fully Sprinklered or 2) Fire Resistive or
Masonry Non-Combustible construction?
 N/A Yes No
SWIMMING POOL INFORMATION
1. Does the applicant have any swimming pools? Yes No
a. If yes, are there diving boards? Yes No
b. If yes, are all pools fenced and secured with self locking gates? Yes No
c. If yes, Do all pools contain clearly marked “Swim at Your Own Risk” signs and depth markers Yes No
AUTOMOBILE EXPOSURE
1. Does the applicant have any Owned Autos?
(If No, proceed onto next section)		 Yes No
 
Type # of Owned Units Describe General Use
Private Passenger / SUV
Light Commercial Vehicles
(0-10,000 lbs, including
1 – 8 passenger vans)
Medium Commercial Vehicles
(10,001 – 20,000 lbs, including 9-20 passenger vans)
Buses (over 20 passengers)
Other (Describe)
Totals  
COMMERCIAL EXPOSURES (applicable to incidental and stand-alone commercial exposures)
1. Does the applicant have any Commercial Exposures? (If No, proceed onto next section) Yes No
2. Occupancy

Office
Retail
Restaurant
Light Industrial / Warehouse
Other
3. If Restaurant(s)  
a. Do they maintain Automatic Extinguishing Systems? Yes No
b. Are any restaurant facilities “stand-alone” locations? Yes No
4. If Storage/Warehouse occupancies:
Are any chemicals, explosives or high-hazard materials stored in the storage/warehouse?
 Yes No
5. If Other, please describe:
HOTEL EXPOSURES
1. Does the applicant have Hotel Operations?
(If No, proceed onto next section)		 Yes No
2. Is there any recreation other than swimming pools, in-house health club, or non-professional participation
tennis courts?		 Yes No
a. If Yes, describe other recreation exposures:
3. Is there a restaurant on any of the premises? Yes No
a. If yes, are Automatic Extinguishing Systems in place? Yes No
b. If yes, are liquor receipts greater than 25% of the total restaurant receipts at each restaurant? Yes No
VACANT LAND EXPOSURES
1. Does the applicant have Vacant Land? (If No, proceed onto next section) Yes No
2. How many vacant land locations are there?
3. Is any development/construction planned in the next 12 months? Yes No
4. Are you aware of any activity of any kind on the vacant land resulting from a leasing arrangement with
third parties or from unauthorized access by third parties?		 Yes No
CONDO / CO-OP DIRECTORS OFFICER'S LIABILITY (D&O) EXPOSURES
1. 1. Does the applicant include condo and/or coop units? (If NO, proceed onto next section)
 Yes No
a. If YES, is D&O coverage desired under the umbrella policy for the association(s)? Yes No
LOSS INFORMATION : Must apply to all locations included in submission.
GENERAL LIABILITY
  For General Liability and Products Liability, does the Aggregate Incurred Loss total for the last three (3) years exceed $300,000?
(Loss total must be supported by 3 complete years of currently valued (w/in six months of the proposed effective date) loss runs or loss summary.)
 Yes No
  If the aggregate loss total exceeds $300,0000, please provide a primary loss summary or loss runs.
(six (6) years - currently valued (within six months of the proposed effective date).
 Yes No
  For General Liability and Products Liability, have there been any individual incurred losses in excess of $250,000 in the past three (3) consecutive years? Yes No
  If yes, please provide details of such losses.
AUTOMOBILE
  For Automobile Liability (if applicable), have there been any individual incurred losses in excess of $250,000 in the past three (3) consecutive years? Yes No
  How many incurred losses were in excess of $100,000?
DIRECTORS AND OFFICERS LIABILITY
  For Directors and Officers Liability (if applicable) have there been any incurred losses in the last three (3) consecutive years? Yes No
  If yes, please provide a loss summary or loss runs – (three (3) years – currently valued within six months of the proposed effective date).
NEW PURCHASES / NEW CONSTRUCTION
  If any required loss information is not available for the last three (3) consecutive years, please select a reason:
  New Construction
  New Purchase
  Other, please describe
UNDERLYING COVERAGE INFORMATION
(applies to all locations – if more than one carrier, complete section below for each)
Information below to be supported by a hard copy of the underlying carrier’s GL quote, binder and / or policy. – Quotes and binders must be on insurance carrier letterhead.
  * With respect to the Underlying General Liability coverage:
1. Is there a Self-Insured Retention (SIR)? Yes No
  If yes, SIR Limits $
2. Is there a Deductible? Yes No
  If yes, Ded. Limits $
3. Is the GL Aggregate Limit Per Location? Yes No
a. If Yes, is the GL Aggregate Limit capped in any way? Yes No
b. If yes, what is the cap limit? $
4. Is the GL defense outside of policy limits Yes No

 

Type Carrier Eff. Date Exp. Date Policy Premium Limits
Automobile Liability $ Each Accident (CSL): $
General Liability *
 $ Each Occurrence $
          General Aggregate $
          Products / Completed
Operations		 $
          Advertising Injury /
Personal Injury
(Each Offense):		 $
Employers Liability
 $ Bodily Injury by Accident $
          Bodily Injury by Disease
(Each Employee):		 $
          Bodily Injury by Disease
(Policy Limits):		 $
Liquor Liability $ Each Occurrence: $
Employee Benefits
Liability		 $ Each Claim or
Each Occurrence		 $
Director’s & Officer’s
Liability Claims
Made Only
 $ Each Claim $
Other: $   $

 

THIS ELECTION IS FINAL AND BINDING UPON THE OFFICERS) NAMED UNTIL REVOKED BY THE CORPORATION.

Section 54, Subdivision 6 of the New York State Workers' Compensation Law

 NOTICE TO APPLICANTS: 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 ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.

NOTICE TO ARKANSAS APPLICANTS: "ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON."
NOTICE TO COLORADO APPLICANTS: "IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AUTHORITIES."
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: "WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT."
NOTICE TO FLORIDA APPLICANTS: "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 IN THE THIRD DEGREE." NOTICE TO KENTUCKY APPLICANTS: "ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE 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."
NOTICE TO LOUISIANA APPLICANTS: "ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON."
NOTICE TO MAINE APPLICANTS: "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."
NOTICE TO NEW JERSEY APPLICANTS: "ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES."
NOTICE TO NEW MEXICO APPLICANTS: "ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES."
NOTICE TO NEW YORK APPLICANTS: "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, 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."
NOTICE TO OHIO APPLICANTS: "ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD."
NOTICE TO OKLAHOMA APPLICANTS: "WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY." (365:15-1-10, 36 §3613.1)
NOTICE TO PENNSYLVANIA APPLICANTS: "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."
NOTICE TO TENNESSEE APPLICANTS: "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.
NOTICE TO VIRGINIA APPLICANTS: "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."

PLEASE READ THE FOLLOWING STATEMENT CAREFULLY AND CLICK ON "I AGREE" BELOW WHERE INDICATED.

ALL WRITTEN STATEMENTS, AND SUPPLEMENTAL MATERIALS FURNISHED TO THE INSURER IN CONJUNCTION WITH THIS APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE A PART HEREOF.
THE UNDERSIGNED AUTHORIZED OFFICER OF THE APPLICANT, HAVING MADE DUE INQUIRY (INCLUDING BUT NOT LIMITED TO DUE INQUIRY OF THE LEGAL AND RISK MANAGEMENT DEPARTMENTS), DECLARES THAT TO THE BEST OF HIS KNOWLEDGE AND BELIEF THE STATEMENTS SET FORTH HEREIN OR ATTACHED HERETO ARE TRUE. THE UNDERSIGNED AUTHORIZED OFFICER AGREES THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION (INCLUDING INFORMATION PROVIDED BY ATTACHMENT HERETO) CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE EFFECTIVE DATE OF THE INSURANCE, HE/SHE (UNDERSIGNED) WILL, IN ORDER FOR THE INFORMATION TO BE ACCURATE ON THE EFFECTIVE DATE OF THE INSURANCE, IMMEDIATELY NOTIFY THE INSURER OF SUCH CHANGES, AND THE INSURER MAY WITHDRAW OR MODIFY ANY OUTSTANDING INDICATIONS, QUOTATIONS AND/OR AUTHORIZATIONS OR AGREEMENTS TO BIND THE INSURANCE.
THE UNDERSIGNED, ON BEHALF OF THE APPLICANT, AGREES THAT THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE INSURER TO COMPLETE THE INSURANCE, BUT IT IS AGREED THAT THIS APPLICATION SHALL BE THE BASIS OF ANY COVERAGE ISSUED BY US AND WILL BE ATTACHED TO AND BECOME PART OF THE POLICY.

 

LOCATION QUESTIONS
(answered per location to be covered):
Location Schedule will be accepted on a MS Excel Spreadsheet
(must include all information below)
  What are the total number of locations
included in this proposal?
  Location #
  Name of Property Owner / Association
(If different than Applicant):
  Location Address
  City
  State
  Zip
  Location Exposures
 
Vacant Land   Hotel
Habitational   Other
Commercial      
  If Commercial, identify Occupancy
 
Office   Light Industrial /Warehouse
Retail   Other
Restaurant      
  Year Built
  How many stories are at this location?
  Is the location Fully Sprinklered? Yes No
  Partially Sprinklered? Yes No
  Construction Type
 
Fire Resistive   Masonry Veneer
Masonry
Non-combustible		   Frame
Non-combustible   Other
Masonry      
  Safety features
 
Smoke Alarms
 Yes No   Emergency Lighting
2 means of egress per floor / per location Yes No   None
Central Station Fire Alarm System      
     
  Location #
  Name of Property Owner / Association
(If different than Applicant):
  Location Address
  City
  State
  Zip
  Location Exposures
 
Vacant Land   Hotel
Habitational   Other
Commercial      
  If Commercial, identify Occupancy
 
Office   Light Industrial /Warehouse
Retail   Other
Restaurant      
  Year Built
  How many stories are at this location?
  Is the location Fully Sprinklered? Yes No
  Partially Sprinklered? Yes No
  Construction Type
 
Fire Resistive   Masonry Veneer
Masonry
Non-combustible		   Frame
Non-combustible   Other
Masonry      
  Safety features
 
Smoke Alarms
 Yes No   Emergency Lighting
2 means of egress per floor / per location Yes No   None
Central Station Fire Alarm System      
     
I have read and agree with the terms above.
I agree.
  Your e-mail address
  Your comments