APARTMENT SUPPLEMENTAL APPLICATION
Building Owner Name:
*
Contact Person Full Name
*
First Name
Last Name
Phone Number (Cell)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number (Business)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Years Owned:
*
PROPERTY LOCATIONS:
How Many Property Location do you have
*
Please Select
1
2
3
4
5
6
Property Location 1 address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Property Location 2 address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Property Location 3 address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Property Location 4 address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Property Location 5 address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Property Location 6 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location 1 Occupancy
Apartment Building
Rooming or Boarding House
Apartment Hotel
Location 1 Number of Units:
Location 1 Number of Stories:
Location 1 Percent occupied: (%)
Location 1 Wiring -Confirm if any are present:
Fuses?
Knob & Tube?
Circuit Breakers?
Location 1 (If YES, mark any of the following)
Challenger
Federal Pacific Stab-Lok
GTE Sylvania
Pushmatic
Zinsco
None of the above
Location 1 Aluminum Wiring ?
Yes
No
If YES, repaired via Copalum or Alumniconn connectors?
Yes
No
Handicapped/Disabled Housing Facility?
Yes
No
Location 1 Are more than 30% of tenants subsidized/students?
Yes
No
Year Build:
If over 25 years old, year of building updated: roofing
If over 25 years old, year of building updated: Heating
If over 25 year old, year of building updated: plumbing
If over 25 year old, year of building updated: wiring
If work subbed out, are COI's obtained from all contractors ?
Yes
No
Location 1 Plans for any major renovations (Cost more than 20% of building value)?
Yes
No
Location 1 If work subbed out, are COI's obtained from all contractors ?
Yes
No
Any prior history of bedbugs or of other bug infestations?
Yes
No
Are there smoke detectors:
Yes
No
If YES, procedures in place to ensure units are fully operational?
Yes
No
Hardwired?
Yes
No
Battery?
Yes
No
Where are they located? Individual Units ?
Yes
No
Where are they located? Common Areas?
Yes
No
Are there security Guards on Premises?
Yes
No
If Yes, are the guards armed?
Yes
No
Secondary means of egress provided if over two stories?
Yes
No
Premised lighting in parking areas, walkways and common areas?
Yes
No
Any Assault & Battery incidents in complex during the past five years ?
Yes
No
Is there a Playground on premises?
Yes
No
Type of Equipment:
Any gyms or healthcare facilities (sauna, yoga, studio, etc.)?
Yes
No
If Yes, provide description:
Are grills allowed on decks?
Yes
No
If Yes, what are the stated requirements:
Any lake or pond exposure (other than decorative) ?
Yes
No
Any owned docks/piers?
Yes
No
If Yes, describe length and use of dock:
Number of boat slips:
Any other recreational facilities ?
Yes
No
If YES, describe:
Is there a swimming pool?
Yes
No
If YES, how many?
If YES (Select all that apply)
Diving Board
Depth Marked
Slide
Non-Slip Surface
Lifeguards on Duty when open
Warning Signs and Rules Posted
Pool Completely Fenced With Self Locking Gates
Life Safety Ring Buoy
Scheduled Maintenance in Place
Does the pool comply with the requirements of the Federal Virginia Graeme Baker Pool/Spa
Yes
No
Any whirlpools or hot tubs?
Yes
No
if YES, how many?
Location 1 Are rules and instructions posted?
Yes
No
Location 2 Occupancy
Apartment Building
Rooming or Boarding House
Apartment Hotel
Location 2 Number of Units:
Location 2 Number of Stories:
Location 2 Percent occupied: (%)
Location 2 Wiring -Confirm if any are present:
Fuses?
Knob & Tube?
Circuit Breakers?
Location 2 (If YES, mark any of the following)
Challenger
Federal Pacific Stab-Lok
GTE Sylvania
Pushmatic
Zinsco
None of the above
Location 2 Aluminum Wiring ?
Yes
No
If YES, repaired via Copalum or Alumniconn connectors?
Yes
No
Handicapped/Disabled Housing Facility?
Yes
No
Location 2 Are more than 30% of tenants subsidized/students?
Yes
No
Year Build:
If over 25 years old, year of building updated: roofing
If over 25 years old, year of building updated: Heating
If over 25 year old, year of building updated: plumbing
If work subbed out, are COI's obtained from all contractors ?
Yes
No
Location 2 Plans for any major renovations (Cost more than 20% of building value)?
Yes
No
Location 2 If work subbed out, are COI's obtained from all contractors ?
Yes
No
Any prior history of bedbugs or of other bug infestations?
Yes
No
Are there smoke detectors:
Yes
No
If YES, procedures in place to ensure units are fully operational?
Yes
No
Hardwired?
Yes
No
Battery?
Yes
No
Where are they located? Individual Units ?
Yes
No
Where are they located? Common Areas?
Yes
No
Are there security Guards on Premises?
Yes
No
If Yes, are the guards armed?
Yes
No
Secondary means of egress provided if over two stories?
Yes
No
Premised lighting in parking areas, walkways and common areas?
Yes
No
Any Assault & Battery incidents in complex during the past five years ?
Yes
No
Is there a Playground on premises?
Yes
No
Type of Equipment:
Any gyms or healthcare facilities (sauna, yoga, studio, etc.)?
Yes
No
If Yes, provide description:
Are grills allowed on decks?
Yes
No
If Yes, what are the stated requirements:
Any lake or pond exposure (other than decorative) ?
Yes
No
Any owned docks/piers?
Yes
No
If Yes, describe length and use of dock:
Number of boat slips:
Any other recreational facilities ?
Yes
No
If YES, describe:
Is there a swimming pool?
Yes
No
If YES, how many?
If YES (Select all that apply)
Diving Board
Depth Marked
Slide
Non-Slip Surface
Lifeguards on Duty when open
Warning Signs and Rules Posted
Pool Completely Fenced With Self Locking Gates
Life Safety Ring Buoy
Scheduled Maintenance in Place
Does the pool comply with the requirements of the Federal Virginia Graeme Baker Pool/Spa
Yes
No
Any whirlpools or hot tubs?
Yes
No
if YES, how many?
Location 2 Are rules and instructions posted?
Yes
No
Location 3 Occupancy
Apartment Building
Rooming or Boarding House
Apartment Hotel
Location 3 Number of Units:
Location 3 Number of Stories:
Location 3 Percent occupied: (%)
Location 3 Wiring -Confirm if any are present:
Fuses?
Knob & Tube?
Circuit Breakers?
Location 3 (If YES, mark any of the following)
Challenger
Federal Pacific Stab-Lok
GTE Sylvania
Pushmatic
Zinsco
None of the above
Location 3 Aluminum Wiring ?
Yes
No
If YES, repaired via Copalum or Alumniconn connectors?
Yes
No
Handicapped/Disabled Housing Facility?
Yes
No
Location 3 Are more than 30% of tenants subsidized/students?
Yes
No
Year Build:
If over 25 years old, year of building updated: roofing
If over 25 years old, year of building updated: Heating
If over 25 year old, year of building updated: plumbing
If over 25 year old, year of building updated: wiring
If work subbed out, are COI's obtained from all contractors ?
Yes
No
Location 3 Plans for any major renovations (Cost more than 20% of building value)?
Yes
No
Location 3 If work subbed out, are COI's obtained from all contractors ?
Yes
No
Any prior history of bedbugs or of other bug infestations?
Yes
No
Are there smoke detectors:
Yes
No
If YES, procedures in place to ensure units are fully operational?
Yes
No
Hardwired?
Yes
No
Battery?
Yes
No
Where are they located? Individual Units ?
Yes
No
Where are they located? Common Areas?
Yes
No
Are there security Guards on Premises?
Yes
No
If Yes, are the guards armed?
Yes
No
Secondary means of egress provided if over two stories?
Yes
No
Premised lighting in parking areas, walkways and common areas?
Yes
No
Any Assault & Battery incidents in complex during the past five years ?
Yes
No
Is there a Playground on premises?
Yes
No
Type of Equipment:
Any gyms or healthcare facilities (sauna, yoga, studio, etc.)?
Yes
No
If Yes, provide description:
Are grills allowed on decks?
Yes
No
If Yes, what are the stated requirements:
Any lake or pond exposure (other than decorative) ?
Yes
No
Any owned docks/piers?
Yes
No
If Yes, describe length and use of dock:
Number of boat slips:
Any other recreational facilities ?
Yes
No
If YES, describe:
Is there a swimming pool?
Yes
No
If YES, how many?
If YES (Select all that apply)
Diving Board
Depth Marked
Slide
Non-Slip Surface
Lifeguards on Duty when open
Warning Signs and Rules Posted
Pool Completely Fenced With Self Locking Gates
Life Safety Ring Buoy
Scheduled Maintenance in Place
Does the pool comply with the requirements of the Federal Virginia Graeme Baker Pool/Spa
Yes
No
Any whirlpools or hot tubs?
Yes
No
if YES, how many?
Location 3 Are rules and instructions posted?
Yes
No
Location 4 Occupancy
Apartment Building
Rooming or Boarding House
Apartment Hotel
Location 4 Number of Units:
Location 4 Number of Stories:
Location 4 Percent occupied: (%)
Location 4 Wiring -Confirm if any are present:
Fuses?
Knob & Tube?
Circuit Breakers?
Location 4 (If YES, mark any of the following)
Challenger
Federal Pacific Stab-Lok
GTE Sylvania
Pushmatic
Zinsco
None of the above
Location 4 Aluminum Wiring ?
Yes
No
If YES, repaired via Copalum or Alumniconn connectors?
Yes
No
Disabled Housing Facility/ Senior Housing?
Yes
No
Location 4 Are more than 30% of tenants subsidized/students?
Yes
No
Year Build:
If over 25 years old, year of building updated: roofing
If over 25 years old, year of building updated: Heating
If over 25 year old, year of building updated: plumbing
If over 25 year old, year of building updated: wiring
If work subbed out, are COI's obtained from all contractors ?
Yes
No
Location 4 Plans for any major renovations (Cost more than 20% of building value)?
Yes
No
Location 4 If work subbed out, are COI's obtained from all contractors ?
Yes
No
Any prior history of bedbugs or of other bug infestations?
Yes
No
Are there smoke detectors:
Yes
No
If YES, procedures in place to ensure units are fully operational?
Yes
No
Hardwired?
Yes
No
Battery?
Yes
No
Where are they located? Individual Units ?
Yes
No
Where are they located? Common Areas?
Yes
No
Are there security Guards on Premises?
Yes
No
If Yes, are the guards armed?
Yes
No
Secondary means of egress provided if over two stories?
Yes
No
Premised lighting in parking areas, walkways and common areas?
Yes
No
Any Assault & Battery incidents in complex during the past five years ?
Yes
No
Is there a Playground on premises?
Yes
No
Type of Equipment:
Any gyms or healthcare facilities (sauna, yoga, studio, etc.)?
Yes
No
If Yes, provide description:
Are grills allowed on decks?
Yes
No
If Yes, what are the stated requirements:
Any lake or pond exposure (other than decorative) ?
Yes
No
Any owned docks/piers?
Yes
No
If Yes, describe length and use of dock:
Number of boat slips:
Any other recreational facilities ?
Yes
No
If YES, describe:
Is there a swimming pool?
Yes
No
If YES, how many?
If YES (Select all that apply)
Diving Board
Depth Marked
Slide
Non-Slip Surface
Lifeguards on Duty when open
Warning Signs and Rules Posted
Pool Completely Fenced With Self Locking Gates
Life Safety Ring Buoy
Scheduled Maintenance in Place
Does the pool comply with the requirements of the Federal Virginia Graeme Baker Pool/Spa
Yes
No
Any whirlpools or hot tubs?
Yes
No
if YES, how many?
Location 4 Are rules and instructions posted?
Yes
No
Location 5 Occupancy
Apartment Building
Rooming or Boarding House
Apartment Hotel
Location 5 Number of Units:
Location 5 Number of Stories:
Location 5 Percent occupied: (%)
Location 5 Wiring -Confirm if any are present:
Fuses?
Knob & Tube?
Circuit Breakers?
Location 5 (If YES, mark any of the following)
Challenger
Federal Pacific Stab-Lok
GTE Sylvania
Pushmatic
Zinsco
None of the above
Location 5 Aluminum Wiring ?
Yes
No
If YES, repaired via Copalum or Alumniconn connectors?
Yes
No
Disabled Housing Facility/ Senior Housing?
Yes
No
Location 5 Are more than 30% of tenants subsidized/students?
Yes
No
Year Build:
If over 25 years old, year of building updated: roofing
If over 25 years old, year of building updated: Heating
If over 25 year old, year of building updated: plumbing
If over 25 year old, year of building updated: wiring
If work subbed out, are COI's obtained from all contractors ?
Yes
No
Location 5 Plans for any major renovations (Cost more than 20% of building value)?
Yes
No
Location 5 If work subbed out, are COI's obtained from all contractors ?
Yes
No
Any prior history of bedbugs or of other bug infestations?
Yes
No
Are there smoke detectors:
Yes
No
If YES, procedures in place to ensure units are fully operational?
Yes
No
Hardwired?
Yes
No
Battery?
Yes
No
Where are they located? Individual Units ?
Yes
No
Where are they located? Common Areas?
Yes
No
Are there security Guards on Premises?
Yes
No
If Yes, are the guards armed?
Yes
No
Secondary means of egress provided if over two stories?
Yes
No
Premised lighting in parking areas, walkways and common areas?
Yes
No
Any Assault & Battery incidents in complex during the past five years ?
Yes
No
Is there a Playground on premises?
Yes
No
Type of Equipment:
Any gyms or healthcare facilities (sauna, yoga, studio, etc.)?
Yes
No
If Yes, provide description:
Are grills allowed on decks?
Yes
No
If Yes, what are the stated requirements:
Any lake or pond exposure (other than decorative) ?
Yes
No
Any owned docks/piers?
Yes
No
If Yes, describe length and use of dock:
Number of boat slips:
Any other recreational facilities ?
Yes
No
If YES, describe:
Is there a swimming pool?
Yes
No
If YES, how many?
If YES (Select all that apply)
Diving Board
Depth Marked
Slide
Non-Slip Surface
Lifeguards on Duty when open
Warning Signs and Rules Posted
Pool Completely Fenced With Self Locking Gates
Life Safety Ring Buoy
Scheduled Maintenance in Place
Does the pool comply with the requirements of the Federal Virginia Graeme Baker Pool/Spa
Yes
No
Any whirlpools or hot tubs?
Yes
No
if YES, how many?
Location 5 Are rules and instructions posted?
Yes
No
Location 6 Occupancy
Apartment Building
Rooming or Boarding House
Apartment Hotel
Location 6 Number of Units:
Location 6 Number of Stories:
Location 6 Percent occupied: (%)
Location 6 Wiring -Confirm if any are present:
Fuses?
Knob & Tube?
Circuit Breakers?
Location 6 (If YES, mark any of the following)
Challenger
Federal Pacific Stab-Lok
GTE Sylvania
Pushmatic
Zinsco
None of the above
Location 6 Aluminum Wiring ?
Yes
No
If YES, repaired via Copalum or Alumniconn connectors?
Yes
No
Disabled Housing Facility/ Senior Housing?
Yes
No
Location 6 Are more than 30% of tenants subsidized/students?
Yes
No
Year Build:
If over 25 years old, year of building updated: roofing
If over 25 years old, year of building updated: Heating
If over 25 year old, year of building updated: plumbing
If over 25 year old, year of building updated: wiring
If work subbed out, are COI's obtained from all contractors ?
Yes
No
Location 6 Plans for any major renovations (Cost more than 20% of building value)?
Yes
No
Location 6 If work subbed out, are COI's obtained from all contractors ?
Yes
No
Any prior history of bedbugs or of other bug infestations?
Yes
No
Are there smoke detectors:
Yes
No
If YES, procedures in place to ensure units are fully operational?
Yes
No
Hardwired?
Yes
No
Battery?
Yes
No
Where are they located? Individual Units ?
Yes
No
Where are they located? Common Areas?
Yes
No
Are there security Guards on Premises?
Yes
No
If Yes, are the guards armed?
Yes
No
Secondary means of egress provided if over two stories?
Yes
No
Premised lighting in parking areas, walkways and common areas?
Yes
No
Any Assault & Battery incidents in complex during the past five years ?
Yes
No
Is there a Playground on premises?
Yes
No
Type of Equipment:
Any gyms or healthcare facilities (sauna, yoga, studio, etc.)?
Yes
No
If Yes, provide description:
Are grills allowed on decks?
Yes
No
If Yes, what are the stated requirements:
Any lake or pond exposure (other than decorative) ?
Yes
No
Any owned docks/piers?
Yes
No
If Yes, describe length and use of dock:
Number of boat slips:
Any other recreational facilities ?
Yes
No
If YES, describe:
Is there a swimming pool?
No
Yes
If YES, how many?
If YES (Select all that apply)
Diving Board
Depth Marked
Slide
Non-Slip Surface
Lifeguards on Duty when open
Warning Signs and Rules Posted
Pool Completely Fenced With Self Locking Gates
Life Safety Ring Buoy
Scheduled Maintenance in Place
Does the pool comply with the requirements of the Federal Virginia Graeme Baker Pool/Spa
Yes
No
Any whirlpools or hot tubs?
Yes
No
if YES, how many?
Location 6 Are rules and instructions posted?
Yes
No
Signature of Applicant
*
Title
Agency
Producer Code
Date
/
Month
/
Day
Year
Date
*Signing this application does not bind the applicant or the company to complete the insurance
Please upload or take photo of your current policy.
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