Supplemental Application Form - Apartments, Cooperatives & Condominiums - Greater New York Insurance Companies
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3GREATER NEW YORK INSURANCE COMPANIES
SUPPLEMENTAL APPLICATION - APARTMENTS, COOPERATIVES & CONDOMINIUMS
Applicants Name: _____________________________
Producer: _____________________________________
Applicants Address: ___________________________
City: ________________________
Zip: ____________
Apartment: _______
Cooperative: _______ Condominium: _______
Assisted Living Facility:
Yes
No
Nursing Home Facility:
Yes
No
Exclusive for over age 55
Yes
No If Yes, Please describe in detail _____________________________________________
Dormitory Style Housing
Yes
No If Yes, Please describe in detail _____________________________________________
Other Association/Operation
Yes
No If Yes, Please describe in detail _____________________________________________
Seasonal Occupancy
Yes
No If Yes, Please describe in detail _____________________________________________
Submissions must include Condominium Association By-Laws or Declaration w/Insurance Section and (if applicable), Master
Deed 4-Years of Currently Valued Loss Runs, and (if Frame or Brick Veneer Construction) a Readable Site Plan including
distances between buildings and SOV, which must included square footage of each building & number of units per building.
Has the insured ever acted or do they plan to act as General Contractor or Property Developer?
Yes
No
Is insured involved in any construction operations?
Yes
No
If yes, describe: ___________________________________________________________________________________
1. No of years under present ownership: ______ No. of Units: _______ Number of Stories: ______
Year Built: ______
2. Number of buildings at this location: ____ Distance between each building: ________ Construction type: _________________
Square Feet of Each Building: _____________ Living Space ____________ Basements ____________ Garages ___________
3. Average monthly Apt Rent/Unit: ______ Average monthly Condo Fee/Unit: ______ Total Annual Rental/Condo Fees_________
4. Are there any Mercantile, Office or Other Occupancies?
Yes
No Sq. Ft. _______
Describe Occupancies: _________________________________________________________________________________
5. a) If Condominium, is it 100 % Owner-Occupied?
Yes
No
b) If Condominium, are there any units not occupied by the owner?
Yes
No # Units _____
c) Are there any Vacant Units?
Yes
No # Units _____
d) Are there any Seasonal/Transient Units?
Yes
No
# Units _____
6. If building is over 20 years, indicate when the most recent modernization was completed for each item:
a) Has Heating been updated?
Yes
No Year _______
b) Has Plumbing been updated?
Yes
No Year _______
c) Has Wiring been updated?
Yes
No Year _______
d) Has Roofing been updated?
Yes
No Year _______
e) If yes, indicate type of work performed on each system: ___________________________________________________
f) Has building been Gut Rehabbed?
Yes
No Year _______
g) Has building been converted from prior occupancy?
Yes
No Year _______
h) If yes, describe former occupancy: _____________________________________________________________________
7. a) Are Circuit Breakers Used Throughout?
Yes
No
b) Are any Fuse Systems still in use?
Yes
No
c) Is there any Aluminum Wiring in the units?
Yes
No
d) Is Polybutelene Piping used?
Yes
No
e) Are there any Underground Storage Tanks?
Yes
No
8. a) Are there any Firewalls?
Yes
No
b) If Yes, Do Firewalls Penetrate the Roof?
Yes
No
c) Do Firewalls or fire barriers, if any, extend from the lowest floor level to the Underside
Yes
No
of Roof?
d) Indicate construction type and number of Fire Walls or Fire Barriers: ________________________________________________
e) Indicate Number of Units within each fire division: ____________________________________________________________
9. Describe Second Means of Egress: 2nd Interior Stairwell ________________ Exterior Stairs to Grade _____________________
Fire Escapes to Grade ________________ Fire Balconies (No access to grade) ___________ None _____________
Edition Date: 12/24/2008
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