Apartment Supplemental Application Form
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1Hull
Southern California
Northern California
Pacific Islands
P: (949) 477-5030
P: (209) 474-9100
P: (808) 840-1980
F: (949) 477-5040
F: (866) 217-1815
F: (866) 859-8302
& Company
Lic. #0F60641
APARTMENT SUPPLEMENTAL APPLICATION
General Agent Name
Insured:______________________________________________________ Date:______________________
GENERAL INFORMATION
______ Year Built
When were the following updates performed?
Heating:
___ ____
Electrical:
Is wiring aluminum? ______
Plumbing: ________
Total # of units: ____ How many units with the following exposures:
#____Assisted living, adult foster care, halfway house, homeless shelter or rehabilitation centers (All prohibited)
#_____Converted to condos
#_____Subsidized housing including housing authority
#_____Student housing
#_____Single family dwellings
#_____Spaces used as Mobile home parks or courts (Not Eligible for Apartment Program)
#_____Timeshares (Not Eligible for Apartment Program)
#_____Undergoing major renovations
Is there an apartment manager on premises? ________What are the average monthly rents _____
•
Have there been any incidents of unlawful eviction within the last 3 years? _____
•
Have there been any violations of any city, county or state housing code within the last three years? ____
•
Occupancy Rate ______
#Stories ________If over 4 stories confirm building is 100% sprinklered, masonry non-combustible
(or better) construction, life safety standards are met and an elevator maintenance agreement is in effect.
Streets or roads: Controlled by the insured? ______If yes, how many miles? _____
LIFE SAFETY &SECURITY
______Confirm Fire Extinguishers are adequately placed and currently tagged
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______Confirm Security Guards are not armed (Armed guards are prohibited)
RECREATIONAL FACILITIES
#_____Baseball diamonds, basketball, racquetball, shuffleboard, tennis or valley ball courts
#_____Beach fronts or lakes. Acres of each lake _____
#_____Bicycle trails Miles of each_____
#_____Clubhouses – square footage of clubhouse _____, #Convenience Stores ______# Fitness Centers _____
#_____Docks
#_____ Slips
#_____ Boat ramps
#_____Playgrounds or parks?
# park acres ______
#_____Restaurants – If restaurant, attach Restaurant/Tavern/Bar Supplemental Application
#____
Swimming Pools
# Saunas _____# Spas_____
Confirm pools are fenced with self-latching gates
_____
Confirm rules, hours and depth markers posted
_____
Confirm life safety equipment is available
_____
Confirm no slides or diving boards (Prohibited)
_____
Describe all losses in the past 3 years:
Has insurance been canceled or non-renewed in the past year for non compliance of recommendations?____
Has applicant filed Bankruptcy (Chapter 7, 11 or 13) or is applicant in receivership? ____
I hereby certify that all information is accurate to the best of my knowledge.
Applicant Signature:
Date:
Producer Signature:
____ _________________
Date: _____________________
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Parent category: Business