Tenant Legal Liability Application

Fill out the below form to obtain your Master Policy number.

Name of Company(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Company Email(Required)

Form created, notifications created. Webpage still outstanding

Number of Eligible Units(Required)

Primary Asset Type(Required)

Single/Multi Family or Student Housing

Manufactured Housing

Single/Multi Family or Student Housing

Policy Start Date(Required)

If there is a specific date you'd like the master policy to begin, please wait to fill out this form until the month prior.

Liability Coverage Amount(Required)

for Single/Multi Family or Student Housing

Liability Coverage Amount(Required)

for Manufactures Housing

Pricing Information(Required)

*Flat monthly fee, no prorating* for Single/Multi Family or Student Housing

Pricing Information(Required)

*Flat monthly fee, no prorating* for Manufactured Housing

Pricing Information(Required)

*Flat monthly fee, no prorating* for Single/Multi Family or Student Housing

Pricing Information(Required)

*Flat monthly fee, no prorating* for Manufactured Housing

Pricing Information(Required)

*Flat monthly fee, no prorating* for Single/Multi Family or Student Housing

Pricing Information(Required)

*Flat monthly fee, no prorating* for Manufactured Housing

Secondary Asset Type(Required)

Single/Multi Family or Student Housing

Manufactured Housing

None

Secondary Policy Start Date(Required)

If there is a specific date you'd like the master policy to begin, please wait to fill out this form until the month prior.

Secondary Liability Coverage Amount(Required)

for Single/Multi Family or Student Housing

Secondary Liability Coverage Amount(Required)

for Manufactured Housing

Secondary Pricing Information(Required)

*Flat monthly fee, no prorating* for Single/Multi Family or Student Housing

Secondary Pricing Information(Required)

*Flat monthly fee, no prorating* for Manufactured Housing

Pricing Information(Required)

*Flat monthly fee, no prorating* for Single/Multi Family or Student Housing

Pricing Information(Required)

*Flat monthly fee, no prorating* for Manufactured housing

Pricing Information(Required)

*Flat monthly fee, no prorating* for Single/Multi Family or Student Housing

Pricing Information(Required)

*Flat monthly fee, no prorating* for Manufactured Housing

Terms & Conditions(Required)

By submitting the above form, the 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 Company as soon as practicable and the Company 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. In addition to adherence with the above, you represent that all information is true to the best of your knowledge and you validate the Property Management Company has the authorized authority to secure insurance on behalf of the landlord they are servicing. You are also aware that we have the right to use third party data sources such as CLUE to validate information provided on this application.

STATE APPLICANT FRAUD WARNINGS

NOTICE TO ALABAMA 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.

NOTICE TO ARKANSAS 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 CALIFORNIA 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 COLORADO 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 a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

NOTICE TO DISTRICT OF COLUMBIA 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 FLORIDA 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 KENTUCKY 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 LOUISIANA 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 MAINE 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, or denial of insurance benefits.

NOTICE TO MARYLAND 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 NEW JERSEY 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 NEW MEXICO 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 NEW YORK 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.

NOTICE TO OHIO 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 OKLAHOMA 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 PENNSYLVANIA 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 RHODE ISLAND 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 TENNESSEE 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 VIRGINIA 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 WASHINGTON 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 WEST VIRGINIA 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 ALL OTHER STATES: Any person who knowingly and willfully presents false information in an application for insurance may be guilty of insurance fraud and subject to fines and confinement in prison.

By checking this box, I agree to the Terms & Conditions.

Name(Required)

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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