Glazd Property Manager & Landlord Protection Application

Glazd Property Manager & Landlord Protection Application
Insured Information

Provide Company and contact information
Requested effective date (ie: when do you want to launch your program?)

MonthDayYear
Date
Company Address*

Street address

Street Address Line 2

CityState

Zip code
Name insured (Company Name)*
Insured contact (First and Last name)*
Insured email*
example@example.com
Insured Phone Number*
Please enter a valid phone number.
Property Distribution by State (total number of units)
How many total units do you have under management*
What States do you have units in? *
How many units do you have in each respective State? Provide the number in the same order that you have the states listed above. *
# of units by State
Property manager experience years (Company or Personal experience - whichever is greater)*
Years of experience
Coverages

In this section you'll fill out your custom coverages that you want to have on your Master Policy.
How much Liability do you want your residents to have? *
Do you want to provide Pet Damage insurance? This covers damage to the unit, in excess of the security deposit, for pet caused damage. $1,000 in coverage with a $250 deductible.

YesNo
Do you want Tenants that are enrolled into this policy to have Personal Contents Coverage and Loss of Use? Note: This typically increases the policy by $3/unit/month*

YesNo
If you selected Yes for personal contents coverage, how much Personal Property coverage do you want Tenants to Receive? Each $5,000 increment in coverage increases the premium by roughly $3/unit/month
Would you like to submit multiple quotes for different coverages?

YesNo
If Yes, what other coverage combinations do you want to see pricing for?
Enter coverage combinations
Portfolio Information

When filling out the total units below, read carefully. IMPORTANT: The total amount of units that you have listed above under management should equal to the 3 fields below. If you have a question, email Austin (austin@glazd.com)
How many total multifamily(properties with 4+ units) units do you have that are 1-2 stories? *
How many total multifamily(properties with 4+ units) units do you have that are 3+ stories? *
How many total residential(single family or duplexes) units do you have? *
Underwriting

Please read each question carefully. The more accurate the data, the better. However, educated guesses are accepted.
Do all tenant leases require liability insurance?*

YesNo
If Yes limits required in your lease
What are your vacancy rates, as a percent, over the last 12 months? *
What are your turnover rates, as a percent, over the last 12 months? *
Average deposit*
Are dogs allowed, other than service animals?*

YesNo
Average pet deposit amount (if applicable)
Do you do regular inspections?*

YesNo
If Yes, what's the frequency? *
Do you utilize on-site property managers?*

YesNo
What is the average rent monthly?*
Historical Premium & Loss Information

Please attach available experience reports and policy forms
Historical Premium & Loss Information

This section is only relevant if you have a current Master Program in place. If this is your first time binding a Master Policy, then none of the fields in this section are applicable. If you do have a current Master Policy in place, you'll need to provide a Loss Run Report from your current vendor in addition to a Claim Report - which is a history of claims and cost of those claims.
Prior carrier
Name of Carrier or Insurance Provider
Prior coverage
Ex: $100,000
Prior rate
Enter prior premium
Prior deductibles
Enter prior deductibles
Annual Premium in the last 3 years
Total amount of Premium paid. You can get this from your current provider.
Annual loss incurred last 3 years
Was prior coverage cancelled/non-renewed? If "Yes", please describe below.
If Yes please describe below
State Fraud Warnings Representation:

It is represented to the Company, that the information contained herein is true and that it shall be the basis of the policy of insurance and deemed incorporated therein, should we evidence its acceptance of this application by issuance of a policy. The undersigned hereby authorizes the release of claim information from any prior insurer to the Company. Notice to AK applicants: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law. Notice to AL applicants: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof.

Includes copyrighted material of Insurance Services Office, Inc., with its permission.
Notice to AR, LA, RI AND WV applicants: 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. Notice to AZ applicants: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. Notice to CA applicants: For your protection California law requires the following to appear on this form. 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. Notice to CO applicants: 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 the settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Notice to DE applicants: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. Notice to DC applicants: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Notice to FL applicants: 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. Notice to ID applicants: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony. Notice to IN applicants: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony. Notice to KS applicants: Any person who commits a fraudulent insurance act is guilty of a crime and may be subject to restitution, fines and confinement in prison. A "fraudulent insurance act" means an act committed by 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 personal or commercial insurance which such person knows to contain materially false information concerning any material fact thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto. Notice to KY applicants: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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. Notice to MD applicants: 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. Notice to ME applicants: 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 and denial of insurance benefits. Notice to MN applicants: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. Notice to NH applicants: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20. Notice to NJ applicants: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Notice to NM applicants: 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 civil fines and criminal penalties. Notice to NY applicants: 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.

Includes copyrighted material of Insurance Services Office, Inc., with its permission.
Notice to OH applicants: 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. Notice to OK applicants: 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. Notice to OR applicants: This entire policy shall be void, if whether before or after a loss, the insured has willfully concealed or misrepresented any material fact or circumstance concerning this insurance or the subject thereof, or the interest of the insured therein, or in case of any fraud or false swearing by the insured relating thereto. Notice to PA applicants: 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. Notice to PR applicants: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. Notice to TN, VA and WA applicants: 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. Notice to TX applicants: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Notice to VT applicants: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. Notice to all other states applicants: 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.

BINDING DISCLOSURE: No coverage is bound by this application.

The undersigned officer declares that to the best of their knowledge, the statements included herein and any documents submitted herewith are true, accurate and complete. The undersigned further agrees that if any information supplied herein or in connection with this application changes between the date of this application and the effective date of the insurance, the undersigned will notify the Underwriters as soon as practicable and the Underwriters may modify any quotations or agreements to provide insurance. Any intentional misrepresentation, concealment or omission of a material fact shall be grounds for cancellation, withdrawal or denial of insurance coverage provided. Producer's Signature
Applicants Full Name (please print)
Officer title
Applicants signature

Clear
Date

MonthDayYear
Date
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
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Glazd Property Manager & Landlord Protection Application

Insured Information

Property Distribution by State (total number of units)

Coverages

Portfolio Information

Underwriting

Historical Premium & Loss Information