Commercial Crime Coverage for Community Associations

page 1 of 3Crime 11/12 – USLI

CARRIER:

Commercial Crime Coverage for Community Associations - All States

YOU CAN OBTAIN A QUOTE BY PROVIDING THE INFORMATION IN THE INSTANT QUOTE SECTION SUBJECT TO THE REMAINDER PROVIDED PRIOR TO BINDING.

I. INSTANT QUOTE INFORMATION

Instant Quote is only available for accounts with no losses in the past 5 years. If there is loss history, please complete the entire application.

Applicant’s name:

Location address: q Same as mailing address

City: State: Zip:

E-mail address of primary contact:

Type of Association: q Residential condo q Homeowner q Office park q Cooperative q Retail q Master

q Residential with >25% retail q Mobile home park q Planned unit development q Property Owner

qCondo-hotel q Timeshare

1. Are the total number of units less than 1,000? q Yes q No

2. Does the average unit value exceed $1,000,000? q Yes q No

3. Does the association have a negative fund balance? q Yes q No

4. Does the builder/developer maintain control of the board? q Yes q No

5. Has the association completed a foreclosure sale within the past 24 months? q Yes q No

6. Are over 50% of the total number of units rented or leased? q Yes q No

7. Have any directors and officers or employment practices liability claims been made against the association within the

past five years, or is the association aware of any fact, circumstance, or situation which may result in a claim? q Yes q No

II. CRIME UNDERWRITING INFORMATION

Organization Background

8. Has the association been in operation for more than two years? q Yes q No

9. Are there sources of income other than dues, assessments and investments? If “Yes,” please explain. q Yes q No

Insurance Information

10. Does the organization have crime coverage? q Yes q No

Carrier name: Policy period: Limits carried:

First year of continuous coverage: Premium: Deductible:

11. Does the association have a property manager? q Yes q No

If “Yes,” does the property manager carry insurance for employee theft? q Yes q No

If “No,” does the association segregate duties so no one person has access to or processes an entire transaction? q Yes q No

Organization Operation Details

12. Does the association have an annual financial statement prepared? q Yes q No

13. Is the association’s bank account(s) reconciled by someone other than the person also authorized to withdraw,

deposit or transfer funds? (e.g. quarterly, semi-annually, annually) q Yes q No

14. Do checks written by the association require a countersignature? q Yes q No

Claim Information

15. Within the past five years, have there been any incidents, occurrences or claims for theft, embezzlement, larceny,

robbery, unlawful taking or other forms of dishonesty involving the proposed named insured or any person

proposed for this insurance? q Yes q No

If “Yes,” please advise by separate attachment

16. Is any person proposed for this Insurance aware of any fact, circumstance, or situation that may give rise to a claim

by other forms of dishonesty involving the proposed named insured or any person proposed for this insurance? q Yes q No

If “Yes,” please provide full details by separate attachment.

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Crime 11/12 – USLI

FRAUD STATEMENTS

Alabama, Arkansas, District of Columbia, New Mexico, Rhode Island and West Virginia: Any person who knowingly presents a false or fraudulent claim

for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and

confinement in prison.

California: For your protection California law requires the following to appear on this application. Fraud Statement: Any person who knowingly presents false or

fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and

confinement in state prison.

Colorado Fraud Statement: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose

of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company

or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of

defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the

Colorado division of insurance within the department of regulatory agencies.

Florida Fraud Statement: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application

containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Kansas Fraud Statement: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that

it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral,

or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or

commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows

to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material

thereto; or conceals , for the purpose of misleading, information concerning any fact material thereto may be guilty of a crime and may be subject to fines and

confinement in prison.

Maine Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding

the company. Penalties may include imprisonment, fines or a denial of insurance benefits

Maryland Fraud Statement: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or

willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and

civil penalties.

Ohio Fraud Statement: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim

containing a false or deceptive statement is guilty of insurance fraud.

Oklahoma Fraud Statement: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds

of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Oregon Fraud Statement: Notice to Oregon applicants: Any person who, with intent to defraud or knowing that he is facilitation a fraud against an insurer,

submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.

Kentucky and Pennsylvania Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an

application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any

fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Tennessee, Virginia and Washington Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company

for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

Fraud Statement (All Other States): Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false

information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.

STATE NOTICES

Arizona Notice: Misrepresentations, omissions, concealment of facts and incorrect statements shall prevent recovery under the policy only if the

misrepresentations, omissions, concealment of facts or incorrect statements are; fraudulent or material either to the acceptance of the risk, or to the hazard

assumed by the insurer or the insurer in good faith would either not have issued the policy, or would not have issued a policy in as large an amount, or would not

have provided coverage with respect to the hazard resulting in the loss, if the true facts had been made known to the insurer as required either by the application

for the policy or otherwise.

Florida Surplus Lines Notice: (Applies only if policy is non-admitted) You are agreeing to place coverage in the surplus lines market. Superior coverage may be

available in the admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act with

respect to any right of recovery for the obligation of an insolvent unlicensed insurer.

Florida and Illinois Punitive Damage Notice: I understand that there is no coverage for punitive damages assessed directly against an insured under Florida

and Illinois law. However, I also understand that punitive damages that are not assessed directly against an insured, also known as “vicariously assessed

punitive damages”, are insurable under Florida and Illinois law. Therefore, if any Policy is issued to the Applicant as a result of this Application and such Policy

provides coverage for punitive damages, I understand and acknowledge that the coverage for Claims brought in the State of Florida and Illinois is limited to

“vicariously assessed punitive damages” and that there is no coverage for directly assessed punitive damages.

Maine Notice: The insurer is not permitted to withdraw any binder once issued, but a prospective notice of cancellation may be sent and coverage denied for

fraud or material misrepresentation in obtaining coverage. A policy may not be unilaterally rescinded or voided.

New York Disclosure Notice: This policy is written on a claims made basis and shall provide no coverage for claims arising out of incidents, occurrences or

alleged Wrongful Acts or Wrongful Employment Acts that took place prior to retroactive date, if any, stated on the declarations. This policy shall cover only those

claims made against an insured while the policy remains in effect for incidents reported during the Policy Period or any subsequent renewal of this Policy or any

extended reporting period and all coverage under the policy ceases upon termination of the policy except for the automatic extended reporting period coverage

unless the insured purchases additional extend reporting period coverage. The policy includes an automatic 60 day extended claims reporting period following

the termination of this policy. The Insured may purchase for an additional premium an additional extended reporting period of 12 months, 24 months or 36

months following the termination of this policy. Potential coverage gaps may arise upon the expiration for this extended reporting period. During the first several

years of a claims made relationship, claims-made rates are comparatively lower than occurrence rates. The insured can expect substantial annual premium

increases independent overall rate increases until the claims-made relationship has matured.

Ohio Representation Statement: By acceptance of this policy, the Insured agrees the statements in the application (new or renewal) submitted to the company

are true and correct. It is understood and agreed that, to the extent permitted by law, the Company reserves the right to rescind this policy, or any coverage

provided herein, for material misrepresentations made by the Insured. It is understood and agreed that the statements made in the insurance applications

are incorporated into, and shall form part of, this policy. THE INSURED UNDERSTANDS AND AGREES THAT ANY MATERIAL MISREPRESENTATION

OR OMISSION ON THIS APPLICATION WILL ACT TO RENDER ANY CONTRACT OF INSURANCE NULL AND WITHOUT EFFECT OR PROVIDE THE

COMPANY THE RIGHT TO RESCIND IT.

Utah Punitive Damages Notice: I understand that Punitive Damages are not insurable in the state of Utah. There will be no coverage afforded for Punitive

Damages for any Claim brought in the State of Utah. Any coverage for Punitive Damages will only apply if a Claim is filed in a state which allows punitive or

exemplary damages to be insurable. This may apply if a Claim is brought in another state by a subsidiary or additional location(s) of the Named Insured, outside

the state of Utah, for which coverage is sought under the same policy

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Crime 11/12 – USLI

Missouri and Rhode Island Disclosure Notice: I understand and acknowledge that if a $100,000 or $250,000 Limit of Liability is chosen or if the Insured

Organization has more than 200 employees, that Defense Costs are a part of the Limit of Liability. This means that Defense Costs will reduce my limits of

insurance and may exhaust them completely and should that occur, I shall be liable for any further legal Defense Costs and Damages. Defense Costs are as

defined in Section III. I also understand that the Limit of Liability for the Extended Reporting Period, if applicable, shall be a part of and not in addition to the limit

specified in the Policy Declarations.

Virginia Notice: This Policy is written on a claims-made basis. Please read the policy carefully to understand your coverage. You have an option to purchase

a separate limit of liability for the extended reporting period. If you do not elect this option, the limit of liability for the extended reporting period shall be part of

the and not in addition to limit specified in the declarations. If you have any questions regarding the cost of an extended reporting period, please contact your

insurance company or your insurance agent. Statements in the application shall be deemed the insured’s representations. A statement made in the application or

in any affidavit made before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly proven that such statement was

material to the risk when assumed and was untrue.

If your state requires that we have information regarding your Authorized Retail Agent or Broker, please provide below.

Retail agency name: License #:

Agent’s signature: Main agency phone number:

(Required in New Hampshire)

Agency mailing address:

City: State: Zip:

The signer of this application acknowledges and understands that the information provided in this Application is material to the Insurer’s decision to provide the

requested insurance and is relied on by the Insurer in providing such insurance. The signer of this application represents that the information provided in this

Application is true and correct in all matters. The signer of this Application further represents that any changes in matters inquired about in this Application occurring

prior to the effective date of coverage, which render the information provided herein untrue, incorrect or inaccurate in any way will be reported to the Insurer

immediately in writing. The Insurer reserves the right to modify or withdraw any quote or binder issued if such changes are material to the insurability or premium

charged, based on the Insurer’s underwriting guides. The Insurer is hereby authorized, but not required, to make any investigation and inquiry in connection with

the information, statements and disclosures provided in this Application. The decision of the Insurer not to make or to limit any investigation or inquiry shall not be

deemed a waiver of any rights by the Insurer and shall not estop the Insurer from relying on any statement in this Application in the event the Policy is issued. It is

agreed that this Application shall be the basis of the contract should a Policy be issued and it will be attached and become a part of the Policy.

New York Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance

or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto,

commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the

claim for each such violation.

Applicant’s signature: Title:

President or Chairperson

Date:

page 1 of 1Privacy Notice 11/21 – USLI

Privacy Notice At Collection

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on how we store, use and protect personal information, please see our Privacy Policy accessible on our website,

https://www.usli.com/privacy-policy/.