Apartment/dwelling Supplemental Application Form 2009 Page 2
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4Have you had any Assault or Battery incidents within the past 3
years at this location(s) to be insured, or any other location
Yes
No
Yes
No
Yes
No
owned or managed by, or in which you have an ownership
interest? This would include any police calls to the premises
If the answer to the above question is “Yes”, please advise the
location address; month/year the incident occurred; and the
nature of the incident and injuries:
RECREATIONAL FACILITIES
Loc
/ Bldg
Loc
/ Bldg
Loc
/ Bldg
Number of Pools
Is the pool area fenced from all units?
Yes
No
Yes
No
Yes
No
Self-locking gates?
Yes
No
Yes
No
Yes
No
Does pool have depth markers?
Yes
No
Yes
No
Yes
No
Is there lifesaving equipment in place?
Yes
No
Yes
No
Yes
No
Is there a lifeguard? (If not certified, refer to Seneca
Yes
No
Yes
No
Yes
No
underwriter)
Have a diving board? (If over 1 meter long, refer to Seneca
Yes
No
Yes
No
Yes
No
underwriter)
Have a sliding board? (If “Yes”, the risk is prohibited)
Yes
No
Yes
No
Yes
No
Describe playground equipment (i.e. fenced, installed per specs.
condition, etc)
Describe any exercise facilities (i.e. types of equipment & safety
requirements)
Describe any outside recreation (e.g., tennis/handball courts,
boating, horseback riding, etc.)
OTHER
Loc
/ Bldg
Loc
/ Bldg
Loc
/ Bldg
Average rent:
1 Bedroom
2 Bedroom
3 Bedroom
Square Footage:
1 Bedroom
2 Bedroom
3 Bedroom
# of HUD Units
% Rented to Students
% Rented to Elderly
Hourly or Daily Rentals
Yes
No
Yes
No
Yes
No
If “Yes”, describe:
_______________
_______________
_______________
Does lease/rental agreement make any warranty with regard to
Yes
No
Yes
No
Yes
No
security
Are leasing agents/employees instructed to advise
Yes
No
Yes
No
Yes
No
tenants/prospective tenants to call 911 in case of emergency?
LOSS INFORMATION
Was prior coverage ever cancelled or non-
Yes
No
If “Yes”, please explain:
Loss information for the past 3 years:
No losses
No prior coverage
Year
# 0f Claims
Incurred
Description
Amounts
Seneca Apartment Supplemental
2
09/09
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