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CHUBB GROUP OF INSURANCE COMPANIES CHUBB GROUP OF INSURANCE COMPANIES
c/o Preferred Property & JGS Insurance Low Limit Product
960 Holmdel Road, Building II,
Holmdel, New Jersey 07733
Phone: (877) 807-8708
Fax: (213) 627-5006



PPP/JGS FORM 09/03
Low Limit Umbrella App 1-5 Million
Insurance Agency
Contact Person
Phone # Fax #
***COMMUNITY ASSOCIATION QUESTIONNAIRE***

All Sections MUST be Completed
NAMED INSURED:
CARE OF:
MAILING ADDRESS (Street, City,
State and Zip):

LOCATION ADDRESS (Street, City):
LOCATION ADDRESS (State, Zip) :
DESCRIPTION OF OPERATION:
(i.e. standard Condo; Office Condo consisting of professional
offices, etc.)


.

(If occupied by tenants other than
habitational, please list)


EFFECTIVE DATE: to (EXPIRATION MUST COINCIDE WITH
GL)
Current Carrier Current Limit:
Current Premium
DESIRED UMBRELLA LIMIT:
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
Other (specify)
GENERAL RATING INFORMATION
TYPE OF ASSOCIATION:
HOA
Condo
PUD
POA
Other Explain
NUMBER OF BUILDINGS:
(Important)

NUMBER OF UNITS
NUMBER OF STORIES
CONSTRUCTION TYPE
Frame
Joisted Masonry
Non-Combustible

Masonry Non-Combustible
Fire Resistive
Other
Sprinkler System
None
100%
Common Areas Only
Partial Explain

Smoke Detectors
None
Every Unit
Common Areas Only
Electric
Battery Operated
Maintenance Schedule

Year Built



MUST COMPLETE
Emergency Lighting? Yes
No
Manual Pull Alarms Yes
No
Annunciator Panels? Yes
No
Elevator Recall Yes
No

FOR BUILDINGS OVER 4 Stories
Two Exits Per Floor? Yes
No
Interior Fire Walls?
Yes
No
Central Station Alarm?
Yes
No
Fire alarms keyed to central station
Yes
No
Enclosed Stairwells
Yes
No



IS TERRORISM ON GL
INCLUDED
EXCLUDED
TERRORISM FOR UMBRELLA
INCLUDE?
EXCLUDE?

CHUBB GROUP OF INSURANCE COMPANIES
c/o Preferred Property & JGS Insurance Low Limit Product


PPP/JGS app 0903
Low Limit Umbrella App 1-5 Million


AUTO EXPOSURE:
N/A
HIRED NON OWNED AUTO
ONLY
Yes
No

# of AUTOMOBILES
in Total
light PPV
MEDIUM
HEAVY


SWIMMING POOLS?
yes
no
Number of pools
Diving Board?
yes
no
Fenced in?
yes
no
PARKING GARAGES?
yes
no
Number of spaces
Garage Sprinklered?
yes
no
Attendant
yes
no
ANY LIABILITY CLAIMS OVER
$25,000?
yes (attach loss runs)
no

PRIMARY CARRIER EXCLUDE OR SUBLIMIT LEAD PAINT LIABILITY?

Yes (umbrella will exclude)
no (umbrella will exclude)


Liability Exclusions and Endorsements: Check All that Apply:
Standard ISO Forms

Punitive Damages Exclusion
Physical/Sexual Abuse
Lead Contamination Exclusion
Employment Related Exclusion
Terrorism
Assault and Battery Exclusion

Designated Premises Limitation
Mold /Fungus
/Spore
Asbestos Exclusion

Professional Liability Exclusion

Other (list)

UNDERLYING SCHEDULE
All Carriers must have an A-VI AM Bests rating or better
GENERAL LIABILITY CARRIER:
POLICY NO.:
LIMITS:
AGGREGATE:
PREMIUM:

EFFECTIVE DATE:
EXPIRATION:


D & O CARRIER:
POLICY NO.:
LIMITS (Minimum $2,000,000):
$2,000,000
AGGREGATE:
DEFENSE INCL. IN LIMIT?
yes
no

PREMIUM:

EFFECTIVE DATE:
EXPIRATION:


AUTOMOBILE CARRIER:
POLICY NO.:
LIMITS:
PREMIUM:
EFFECTIVE DATE:
EXPIRATION:


EMPLOYERS LIABILITY
CARRIER:

Policy No.:
LIMITS (500/500/500 Minimum):
MINIMUM LIMIT of
$500K/$500K/$500K
EFFECTIVE DATE:
EXPIRATION: