USI Condo - Quote Request Form

Quote Request Form

QUOTE INFORMATION

SECTION 1

Requestor Information

First Name:

Last Name:

Email:

Community Association
Name:

Condo, Coop or HOA:

Location:

Property Manager Name:

Property Manager Phone:

Management Company

Company Name:

Address1:

Address2:

City:

State:

ZIP:

On-site Manager:

Phone:

SECTION 2

Current Coverage Description

Name of Company:

Name of Agent:

Expiration Date:

Property Insurance Limits

Building:

Personal Property:

Loss of Income:

Property Insurance
Deductible:

Liability Insurance Limits

General Liability:

D&O Liability:

Umbrella Liability:

Fidelity Bond
Insurance Limit:

Boiler & Machinery
Insurance Limit:

SECTION 3

Worker's Compensation
Insurance Annual Payroll

Clerical (8810)

Manager (9012)

Building-NOC (9015)

Owned Automobile Insurance

Please list year, make, model & purchase price for each automobile or truck owned by the Association under miscellaneous information and comments in Step 4.

Liability Limit

Deductibles

Comprehensive:

Collision:

STEP 4

General Information

Number of Buildings:
Number of Stories:
Number of Units:
Year Built:
Square Footage:
Construction Type:
% of Commercial Occupancy:
Number of Employees:
Number of Swimming Pools:

Click Yes or No for the following items:

24 Hour Security:	Yes No
Closed Circuit Cameras:	Yes No
Central Station Alarm System:	Yes No
Evacuation Plan:	Yes No
Hard Wire Smoke Detectors:	Yes No
On-Site Maintenance Personnel:	Yes No
Playgrounds/Tot Lots:	Yes No
Written Maintenance Program:	Yes No
Fully Sprinklered:	Yes No

Swimming Pools

Diving Boards:	Yes No
Lifeguard:	Yes No
Fenced:	Yes No

If the building(s) are more than 20 years old, have any of the major systems (i.e., heating, plumbing, electrical, etc.) been updated? If so, please describe what has been done and when.

Association's
Federal Tax ID:

Documentation required to complete quote:

1) Bylaw Insurance Requirements.

2) 3 year Claim History.

Miscellaneous Information and Comments:


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