Name of Insurance Company to which Application is made (herein called the 'Insurer")

NOT-FOR-PROFIT PROTECTOR sm
Not-for-Profit Individual and Organization Insurance Policy
Including Employment Practices Liability Insurance

Condominium/Cooperation Homeowner Association Renewal Application

Name of Insurance Policy to which Application is applicable

NOTICE: THE POLICY PROVIDES THAT THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGEMENTS OR SETTLEMENTS SHALL BE REDUCED BY AMOUNTS INCURRED FOR LEGAL DEFENSE. FURTHER NOTE THAT AMOUNTS INCURRED FOR LEGAL DEFENSE SHALL BE APPLIED AGAINST THE RETENTION AMOUNT. IF A POLICY IS ISSUED, IT WILL BE ON A CLAIMS-MADE BASIS.
SECTION A : GENERAL INFORMATION
1. Has the Internal Revenue Service issued a letter stating that the Applicant qualifies as a not-for-profit organization? Yes
No
2a. Name of Applicant
2b. Address of Applicant
3a. Name of Property Manager
3b. Address of Property Manager
3c. The words "Association" and "Applicant(s)" refer to the Applicant named in question 2 and all the other entities applying for coverage. If your answer to any question in this Application requires additional space, please complete your answer here.
4 Does the Property Manager handle Insurance issues on behalf of the Named Applicant?
 Yes
No
SECTION B : FINANCIAL INFORMATION
1. Has any auditor issued a “going concern" opinion for the Applicant or any of its Subsidiaries' financial statements or is the Applicant or any of its Subsidiaries declaring bankruptcy or has the Applicant or any of its Subsidiaries declared bankruptcy or operated under a different name over the past year?

Yes No
2. Please provide the following Financial Information for the Applicant and its Subsidiaries.
2a. Based on Financial Statements Dated
2b. Total Value of Property
 $
2c. Average Unit Value $
2d. Current Assets $
2e. Total Liabilities $
2f. Fund Balance $
2g. Revenues /Contributions $
2h. Net type

Income Loss

2i. Net $
2j. Net Income for the prior year ending
 $
3. Years of Operation?

Less than 1 Year
1 - 2 Years
3 - 4 Years
4 - 5 Years
Over 5 Years
4. Date of Incorporation
SECTION C : ASSOCIATION INFORMATION
1. Association Type Condominium
PUD (Planned Unit Development)
Homeowners
Master
Cooperative
Timeshare/Interval Ownership
Mobile Home
Commercial
2a. Total number of units / lots at final build-out
2b. Total number of units built currently / lots sold currently
2c. Total number of units rented / leased
2d. Are any units rented daily or weekly? Yes No
  If yes, how many?
2e. Total number of units that are detached (e.g. detached homes)
2f. Total number of stories that Association occupies
3. Are there any timeshare units in the Association? Yes No
  If "Yes", please write a description of the details.
4. Does the Association have any commercial occupancy (e.g. restaurant, office, etc.)? Yes No
  If "Yes," what % of units are commercial and please attach a description of occupancy. %
5. If the Association is a commercial Association, what percentage of units are rented/leased to tenants (e.g., percentage of units not occupied by the owners)? %
6. Does the Association have any recreational facilities? (e.g. golf course(s), pool(s), etc) Yes No
  If "Yes," please attach a description of the details, include the number of facilities, size and whether such facility is open to the general public.
7. Is there a sponsor, developer or builder or his/her representative on the board? Yes No
8. Does the developer control the board? Yes No
9. Does the Applicant have indemnification provisions in the charter or by-laws? Yes No
10. Are medical services provided or medical advice given? Yes No
11. Are childcare services provided? Yes No
12. Does the Applicant act as a general partner of any limited partnership(s) and/or a partnership Manager of any general partnership(s), and/or joint venture Manager of any joint venture(s)? Yes No
13. Has a discrimination or harassment claim been filed against an executive or officer in past year? Yes No
  If "Yes," please attach a description of each claim, the disposition of same and the disciplinary action taken against that executive or officer.
14

Please Complete the Grid below:

Number of Employees: CA DC, FL, TX or MI All Other States
Full-Time
Part-Time
Volunteers
SECTION E: POLICY COVERAGE DETAILS
1. Amount of aggregate limit requested $
2. Self-Insured Retention for D&O $
3. Self-Insured Retention for EPLI (Each Loss): $
 
     

WE HAVE THE RIGHT TO ASK FOR THE FOLLOWING ADDITIONAL INFORMATION:

  1. Completed, Signed and Currently Dated Original Renewal Application.
  2. Copy of the indemnification provisions of the Applicant's charter and by-laws.
  3. Latest Applicant Financials (with Treasurer's Warranty Letter if not audited.)
  4. Any and all additional information or documentation the Insurer may require to underwrite this policy.

THE UNDERSIGNED AUTHORIZED OFFICER OF THE APPLICANT DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE. THE UNDERSIGNED AUTHORIZED OFFICER AGREES THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION 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 QUOTATIONS AND/OR AUTHORIZATIONS OR AGREEMENTS TO BIND THE INSURANCE.

SIGNING OF THIS APPUCATION DOES NOT BIND THE APPLICANT OR THE INSURER TO COMPLETE THE INSURANCE, BUT IT IS AGREED THAT THIS APPLICATION SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED, AND IT WILL BE ATTACHED TO AND BECOME PART OF THE POUCY.

ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE INSURER IN CONJUNCTION WITH THIS APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE A PART HEREOF.

NOTICE TO APPUCANTS: 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 MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.

NOTICE TO ARKANSAS AND 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 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 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, 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.

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 (365:151 10, 36 43613.1).

NOTICE TO PENNSYLVANIA APPIJCANTS: 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 AND 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.
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