P: (516) 431-8300 ∙ (866) 431-8300 ∙ F: (516) 431-5351
COMMERCIAL UMBRELLA APPLICATION
PRODUCER INFORMATION
AGENCY / SUBMITTED BY
ADDRESS / AGENCY PHONE / FAX
CITY / ST / ZIP / SUBMITTOR EMAIL
IN ORDER TO RECEIVE A QUOTE, THE FOLLOWING IS REQUIRED:
- THIS APPLICATION COMPLETED IN ITS ENTIRETY, AND SIGNED BY THE ABOVE AGENT
- 5 YEARS OF CURRENTLY VALUED LOSS HISTORY
- ANY APPLICABLE SUPPLEMENTAL FORMS
CERTIFICATE INFORMATION
LIMIT(S) REQUESTED / $5 MILLION / $15 MILLION / $50 MILLION / $100 MILLION
$10 MILLION / $25 MILLION / $75 MILLION
EFFECTIVE DATE: / EXPIRATION DATE:
FIRST NAMED INSURED:
C/O
MAILING ADDRESS
CITY / ST / ZIP
LIST ALL ADDITIONAL FIRST NAMED INSURED (IF APPLICABLE):
INSPECTION CONTACT: / PHONE:
DOES THE ABOVE AGENCY CURRENTLY CONTROL THE PRIMARY ACCOUNTS? / YES / NO
IS THIS RISK CURRENTLY PARTICIPATING IN A COMMERCIAL UMBRELLA PROGRAM? / YES / NO
IF CURRENTLY IN AN UMBRELLA PROGRAM, WHICH COMPANIES PROVIDE THE COVERAGE?
WHAT IS THE EXPIRING UMBRELLA PREMIUM (IF APPLICABLE)?
HOW MANY LOCATIONS TO BE QUOTED? / *
ARE ANY OTHER LOCATIONS OWNED BY THIS NAMED INSURED? / YES / NO
IS THIS ACCOUNT A RESIDENTIAL RISK (INCLUDING MIXED OCCUPANCY) OR STRICTLY COMMERCIAL?
(*IF MORE THAN ONE LOCATION, AN APPLICATION MUST BE COMPLETED FOR EACH LOCATION, OR EQUIVALENT FORM SUBMITTED CONTAINING ALL INFORMATION CONTAINED ON THIS APPLICATION FOR EACH LOCATION)
LOCATION INFORMATION
STREET ADDRESS / CITY / ST / ZIP
STORIES / BUILDING SQUARE FOOTAGE / YEAR BUILT
CONSTRUCTION: / FRAME / FIRE RESISTIVE / OTHER (SPECIFY):
JOISTED MASONRY / NON-COMBUSTIBLE
VACANT LAND*
IS THERE A VACANT LAND EXPOSURE? / YES / NO / IF YES, HOW MANY ACRES?
IS THERE ANY DEVELOPMENT PLANNED ON THIS LAND DURING THE REQUESTED TERM? / YES / NO
*VACANT LAND MAY NOT BE COVERED ON A STANDALONE BASIS. ADDRESS/LOT NUMBER OF VACANT LOT REQUIRED.
HAVE THERE BEEN ANY INDIVIDUAL LOSSES EXCEEDING $25,000? / YES / NO
HAVE THERE BEEN AGGREGATE LOSSES EXCEEDING $50,000? / YES / NO
COMMERCIAL UMBRELLA APPLICATION / PAGE 1 OF 3 / VERSION 3.07
/ 100 N. CENTRE AVENUE – STE 500 ∙ ROCKVILLE CENTRE, NY11570
P: (516) 431-8300 ∙ (866) 431-8300 ∙ F: (516) 431-5351
RESIDENTIAL RISKS (COMMERCIAL RISKS, SKIP TO “COMMERCIAL RISKS” SECTION)
TYPE OF EXPOSURE: / COMMUNITY ASSOCATION (COOP/CONDO/HOA) / RENTAL OCCUPANCY
# OF UNITS / IS THERE A COMMERCIAL OCCUPANCY IN THIS BUILDING? / YES / NO
IF YES, WHAT IS THE SQUARE FOOTAGE OF THE COMMERCIAL OCCUPANCY?
LIST ALL COMMERCIAL OCCUPANCIES:
DOES THE INSURED MAINTAIN COPIES OF CERTIFICATES OF INSURANCE FOR ABOVE? / YES / NO / N/A
DOES THE LEASE CONTAIN A HOLD HARMLESS AGREEMENT FAVORING ONLY THE INSURED? / YES / NO / N/A
DOES INSURED REQUIRE AND DOCUMENT FAVORABLE HOLD HARMLESS/RISK TRANSFER AGREEMENTS AND CERTIFICATES OF INSURANCE FROM ALL CONTRACTORS ENTERING OR WORKING ON ANY INSURED PREMISES? / YES / NO
IS THIS LOCATION:
LESS THAN 80% OCCUPIED? / YES / NO
UNDERGOING CONSTRUCTION OF ANY KIND? / YES / NO
SENIOR HOUSING? / YES / NO
IF YES, ARE THERE MEDICAL OR ASSISTED LIVING FACILITIES? / YES / NO
STUDENT HOUSING? / YES / NO
A HOUSING/DEVELOPMENT PROJECT, SECTION 8 OR AFFORDABLE HOUSINGBUILDING? / YES / NO
IN RECEIPT A GOVERNMENT SUBSIDY OF ANY KIND? / YES / NO
IF YES, WHAT PERCENTAGE OF UNITS RECEIVE A SUBSIDY?
IS THE BUILDING OWNED BY A HOUSING AUTHORITY? / YES / NO
DOES THIS BUILDING CONTAIN A:
DAYCARE OR CHILDDEVELOPMENTCENTER? / YES / NO
DRY CLEANER PERFORMING WORK ON THE PREMISES? / YES / NO
HEALTH CLUB? / YES / NO
RESTAURANT? / YES / NO
IF YES, ARE ALCOHOL SALES GREATER THAN 50% OF ITS RECEIPTS? / YES / NO
PUBLIC PARKING LOT? / YES / NO
IF YES, TOTAL # OF PARKING SPOTS
TOTAL SQUARE FOOTAGE
SWIMMING POOL? / YES / NO
IF YES, HOW MANY?
IS THERE A LIFEGUARD ON DUTY WHEN THE POOL IS IN USE? / YES / NO
IS THERE A FENCE ENCLOSING THE POOL? / YES / NO
IS THERE A DIVING BOARD? / YES / NO
COMMERCIAL RISKS
TYPE OF RISK: / RETAIL STRIP / WAREHOUSE
OFFICEBUILDING / MIX (SPECIFY)
LIST OF TENANTS/OCCUPANCIES:
BUILDING SQUARE FOOTAGE: / PARKING SQUARE FOOTAGE (IF APPLICABLE)
ARE ALL OCCUPANCIES LESSOR’S RISK EXPOSURES? / YES / NO
DO ALL TENANTS MAINTAIN SEPARATE INSURANCE? / YES / NO
DOES INSURED MAINTAIN COPIES OF CERTIFICATES OF INSURANCE FOR ABOVE? / YES / NO
DOES THE LEASE CONTAIN A HOLD-HARMLESS AGREEMENT FAVORABLE ONLY TO THE INSURED? / YES / NO
DOES INSURED REQUIRE AND DOCUMENT FAVORABLE HOLD HARMLESS/RISK TRANSFER AGREEMENTS AND CERTIFICATES OF INSURANCE FROM ALL CONTRACTORS ENTERING OR WORKING ON ANY INSURED PREMISES? / YES / NO
RETAIL STRIPS – DOES THIS STRIP CONTAIN ANY OF THE FOLLOWING? (CHECK ANY THAT APPLY):
BAR/TAVERN / DAYCARE/CHILD LEARNING CENTER / UPHOLSTERY SHOP
A BILLIARD HALL / MASSAGE PARLOR / AUTO SALES/REPAIR
PET SHOP / SQUARE FOOTAGE OF PARKING LOT (IF APPLICABLE):
WAREHOUSE EXPOSURES – DOES THIS LOCATION STORE(CHECK ANY THAT APPLY):
BURLAP? / EXPLOSIVES/FIREWORKS? / CHEMICALS?
CANDLES OR WAX? / PILLOWS? / RAGS?
CELLULOID GOODS? / QUILTS/COMFORTERS?
COMMERCIAL UMBRELLA APPLICATION / PAGE 1 OF 3 / VERSION 3.07
/ 100 N. CENTRE AVENUE – STE 500 ∙ ROCKVILLE CENTRE, NY11570
P: (516) 431-8300 ∙ (866) 431-8300 ∙ F: (516) 431-5351
LIFE SAFETY/SECURITY INFORMATION
MINIMUM TWO MEANS OF EGRESS FROM EACH FLOOR? / YES / NO
# OF STAIRWELLS / ENCLOSED / OPEN
IS THERE EMERGENCY LIGHTING? / YES / NO
FIRE ESCAPES WHERE REQUIRED? / YES / NO
WINDOW BARS ON ALL APARTMENTS WITH CHILDREN? / YES / NO
ARE SMOKE DETECTORS LOCATED IN ALL UNITS? / NONE / BATTERY / HARD-WIRED
ARE SMOKE DETECTORS LOCATED IN COMMON AREAS? / NONE / BATTERY / HARD-WIRED
SPRINKLER TYPE / NONE / FULL / PARTIAL
HOW MANY ELEVATORS? / NONE
IS THERE A DOORMAN/CONCIERGE? / NONE / PART-TIME / 24 HOURS
IS THERE A BUZZER/INTERCOM SYSTEM? / YES / NO / N/A
ENTRY DOORS LOCKED? / YES / NO / N/A
ROOF DOOR LOCKED? / YES / NO / N/A
ROOF DOOR ALARMED? / YES / NO / N/A
FIRE ALARM TYPE: / NONE / LOCAL / HARD-WIRED
TYPE OF WIRING / COPPER / ALUMINUM / OTHER
ELECTRICAL: / CIRCUIT BREAKERS / FUSES
MOST RECENT UPDATES: / PLUMBING / ROOF / ELECTRICITY
UNDERLYING POLICY INFORMATION
POLICY TYPE / POLICY NUMBER / PREMIUM / LIMIT / CARRIER / EXPIRATION
GENERAL LIABILITY
BUSINESS AUTOMOBILE
DIRECTORS AND OFFICERS
EMPLOYERS LIABILITY
DOES THE GENERAL LIABILITY COVERAGE CONTAIN A MOLD/FUNGUS/BACTERIA EXCLUSION? / YES / NO
IS THERE A PER LOCATION AGGREGATE INCLUDED ON THE GENERAL LIABILITY POLICY? / YES / NO
IS HIRED/NON-OWNED AUTOMOBILE INCLUDED ON THE GENERAL LIABILITY POLICY? / YES / NO
IS THERE A BUSINESS AUTOMOBILE EXPOSURE? / YES / NO
IF YES, PLEASE LIST BY TYPE:
PRIVATE PASSENGER / LIGHT TRUCK / MEDIUM TRUCK / HEAVY TRUCK / OTHER*
*DESCRIPTION OF OTHER:
I CERTIFY THAT ALL INFORMATION CONTAINED ON THIS APPLICATION IS FACTUAL TO THE BEST OF MY KNOWLEDGE:
AGENT SIGNATURE: / DATE:
AGENT NAME (PRINT):
INSURED SIGNATURE: / DATE:
INSURED NAME (PRINT):
COMMERCIAL UMBRELLA APPLICATION / PAGE 1 OF 3 / VERSION 3.07