Landowner'S Program Supplemental Application Form
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26263 North Scottsdale Road, Suite 240 • Scottsdale, Arizona 85250
1-800-873-9442 • Fax (480) 596-7859
LANDOWNER’S PROGRAM SUPPLEMENTAL APPLICATION
(Complete in addition to ACORD General Liability Application)
Name of Applicant:
_____________________________________________________________________________________________________
1. Land Use and Acreage:
Indicate the total acreage applicable to the land in the applicable column and row.
Loc. No.
Vacant Land
Real Estate Development Property
Land Leased to Others
1
2
3
What was the prior use of the land?
_________________________________________________________________________________
Was land ever used as a land fill? ..................................................................................................... q Yes
q No
Any underground fuel tanks on the property?...................................................................................... q Yes
q No
Any below ground mines on the property?.......................................................................................... q Yes
q No
q Not Sealed
If yes:.......................................................................................................................q Sealed
Any dams on the property? .............................................................................................................. q Yes
q No
If yes, complete Dam Questionnaire, GLS-113.
Any lakes on the property?............................................................................................................... q Yes
q No
If yes, number of acres:
_________________________________________________________________________________________
Are there any buildings or equipment on the property?........................................................................ q Yes
q No
If yes, describe:
________________________________________________________________________________________________
________________________________________________________________________________________________________________
2. Real Estate Development Property:
Nature of planned development:
q Residential:
Total number of planned homes and/or home sites?
__________________________________________________________
Townhomes or Condominiums? ............................................................................................ q Yes
q No
q Commercial
q Other:
______________________________________________________________________________________________________
Describe the work to be done:
_______________________________________________________________________________________
Has site preparation work been completed? ....................................................................................... q Yes
q No
If yes, by whom?
_______________________________________________________________________________________________
Expected start date:
Expected completion date:
_____________________________________
______________________________
q Licensed contractor
q Applicant acting as general contractor
Who is performing the work?
q Other:
___________________________________________________________________________
Are certificates of insurance obtained from contractors or subcontractors?............................................. q Yes
q No
WHI-APP-114 (8-02)
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