Single Family HOA Application

Named Insured*
Physical Address*
County*
City*
State*
Zip Code*
Mailing Address:*
City*
State*
Zip Code*
Effective Date*
Date Format: MM slash DD slash YYYY
Expiration Date*
Date Format: MM slash DD slash YYYY
Contact Name*
Telephone*
Management Company Name*
Federal Employers Identification Number (FEIN)*
Total Number of Lots at Build-Out (Improved & Unimproved)*
Completed Number of Homes*
Year Property was Built*
Date Completed*
Date Format: MM slash DD slash YYYY
Please list any Additional Insureds
General Information
Does your HOA comply with all City and State ordinances? (i.e. pools, playground equipment, postings/safety equipment, fire extinguishers, etc)?
- Yes
- No
Is it a Gated Community?
- Yes
- No
Any Water Work/Sewage Treatment/Disposal Facilities?
- Yes
- No
Security
Insured Does not Have Security Guards
- Not Applicable
Any Security Guards on Premises?
- Yes
- No
If yes, are they Armed?
- Yes
- No
If yes, How Many?
Roads
Insured Not Responsible for any Roads
- Not Applicable
Association Maintained Roads?
- Yes
- No
Road Maintenance Agreement with the City?
- Yes
- No
Number of Miles
Biking or Walking Trails
Insured Does Not Have Biking or Walking Trails
- Not Applicable
Does the Association Have any Biking or Walking Trails?
- Yes
- No
Number of Miles
Parks
Insured Does Not Have any Parks
- Not Applicable
Do You Have any Parks?
- Yes
- No
How Many Parks?
Swimming Pools
Insured Does Not Have a Pool
- Not Applicable
How Many Pools?
Are There Lifeguards?
- Yes
- No
Are there any other water features, such as “lazy rivers”, wave pools, water parks, etc?
- Yes
- No
Do you Sponsor a Swim Team?
- Yes
- No
Is There a Self-Closing Gate?
- Yes
- No
Lakes or Ponds
Insured Does Not Have a Lake or Pond
- Not Applicable
How Many Lakes or Ponds?
Is Boating Allowed?
- Yes
- No
Is Fishing Allowed?
- Yes
- No
Is Swimming Allowed?
- Yes
- No
Are Signs Posted?
- Yes
- No
Are There any of the Following Exposures?
- Docks
- Piers
- Marinas
- Dams
- Beaches
- Boat Slips
- Watercraft
If yes, Please Provide Details
Other Amenities
Are there any additional amenities such as golf courses, tennis courts, stables, etc.?
- Yes
- No
If yes, list here
Property Coverage Desired (Please indicate 100% Replacement Cost)
Please indicate which items you wish to have property insurance: Examples include: Amenity Center, Buildings, Fences, Monuments, Entrance Structures, Fountains, Gazebos/Pavilions, Signs, Gates, Etc. (Click on the + sign to add more lines)
Item Amount $
For any buildings and/or amenity centers please list year built and square footage:
Year Built
Sq. Footage
Total Property Limit $
Additional Coverages
DIRECTORS & OFFICERS
Do you Want a Quote for Directors & Officers?
- Yes
- No
Is There a Positive Fund balance?
- Yes
- No
Have you Carried Directors & Officers Before?
- Yes
- No
Number of developer controlled board seats
Any Past Directors & Officers Claims?
- Yes
- No
Number of Board Members
CRIME COVERAGE
Do you want a quote for crime (employee dishonesty)?
- Yes
- No
Limits (Higher limits available upon request)
- $25,000
- $50,000
- $100,000
Deductible
- $250
- $500
- $1,000
- Other
UMBRELLA
Do you want a quote for Umbrella?
- Yes
- No
Limit Requested 1M – 5M (Higher limits available upon request)
WORKERS COMPENSATION
Do you want a quote for Workers Compensation?
- Yes
- No
How many association employees?
NON-OWNED AUTO COVERAGE
Do you want hired and non-owned auto coverage?
- Yes
- No
Separate Policy or include HNO in GL Limits?
CLAIM HISTORY
Has the association had any losses/claims in the past 5 years?
- Yes
- No
If yes, please provide details
Additional Information
THE FOLLOWING ITEMS WILL REQUIRE REFERRAL
- Associations Incorporated as a City
- Golf course exposure owned, operated or maintained
- Associations with fire department
- Recreational use of lakes
I have reviewed and made any necessary changes to this questionnaire.
Sign*
Date*
Date Format: MM slash DD slash YYYY
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Phone: (972) 864-0400 | (888) 895-2300
Address: 3200 Broadway Blvd. Suite 400 | Garland, TX 75043

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Item	Amount $

Single Family HOA Application

General Information

Security

Roads

Biking or Walking Trails

Parks

Swimming Pools

Lakes or Ponds

Other Amenities

Property Coverage Desired (Please indicate 100% Replacement Cost)

Additional Coverages

DIRECTORS & OFFICERS

CRIME COVERAGE

UMBRELLA

WORKERS COMPENSATION

NON-OWNED AUTO COVERAGE

CLAIM HISTORY

THE FOLLOWING ITEMS WILL REQUIRE REFERRAL