Académique Documents
Professionnel Documents
Culture Documents
,-o\
Date sent:
\'.-.-*"*
Transaction number:
Policy numberl
AO customer number:
Balling Account Number:
ProposallD: OrchardTo$rnHomeAss
oTPP-l378587
POLICY INFORITIATION
Date
AgencyCode: 43-0169-00
Agency/Address:
lssue Bound
X ProDosal
12/23/2015
Date:
Policy Effective
Rewrite
12/21t2o15 |
ot
Policy
Term:
D(
Annual
2OO
insure@insurepro.biz
Producer Code:
Company:
01 -
Auto-Owners i
03 -
Home-Owners
l04-Owners
05 -
Property-Owners
08- Southern-Owners
Billlno lnlolmatlon
ADD
ro
CURRENT arLLrNG
ACCOUNT:
L_l
yes
L_.1 No
Blllln9 Optlons:
n
n
Asency
Escrcw
Dcposlt
Bin !
Pay n
rurteay
semr
Mdnod:
Alt.rn.t. Bllllng
Nam
nnual
[:pay
E o,"n"'v
Ma
! c-ast'
! ct'ecr
AulofiBiic Paymenls?
Monthly
credit
card
checkins/Savings
EFI !
! ves
n Yes
D lo
!ruo
egency Sweep
.nd Addr63:
Property Xl General
Liability Cnme
Inland
Marine
APPLICANT INFORMATION
Aoolicanti Orchard Town Home Association
l,4ailing
Entity: Association
Email:
FEINI
DescriDtion of Business ODerations:
Year business
PUD/HOA Assoc
started: o1lo1l2o14
(New
ofowne/s expeience.)
NO
INSPECTION CONTACT
AUDIT CONTACT
Email:
Email:
Accountrng Firm:
55216 (12-12)
Document Integrity
602-7050
PREMISES INFORMATION
Wnhan
LOC
Class Descraption
Program
Bldg
Crty
Lamils
32 - Apartment
365 W 800 N
L|NDON, UT 84042-1337
PREIIIUM MODIFICATION
cumulative i,4ulti-Policy Discount (Provide policy numbrs of other Auto-Owners policies. includinq Lffe & Disabiliq
Discor.:nt J
Policv Tvpe
Policv TvDe
Policv Number
Policy
Number
DE!9!1!L
o/.
'/o
Plan:_o/o
IndividualRiskPremiuml/loditicationFaclor
Coverage Part
Approvedbyi
CrediUDebit
Coverage Part
CrediVDebit
Prior
Losses. 0
Prior Canier Premium
0%
Medt Ratng:
Prior Canier
Prior carriers annual totalexpiring premium (includesr Property, General Liability. Inland Marine and crime):
Has there been continuous coverage for the past three
years?
l Yes
L-.1 No
fl
Y/N
submitEd?
! ves ffi
t'to
Operr/
Closed
No Losses
What action hasthe applicant taken to prevent the type of losses lisled above from recurring?
Premium based on rates
effective:
s5216 (12-12)
C? Documeni Integrity
'10/25i'20'15
Paqe
ol 4
GENERAL INFORMATION
EXPLAIN ALL "YES' RESPONSES
Nonpayment?
fl
n
x
REMARKS
HospitEls,
informatron?
Does the applicant's business retain customers' Social Security Numbers and/or insurance
(Examples Of this risk include apartinents, doctor'S OffiCeS and professionalServices, such as attomeys Or accounte|nls
Does the applicant's busrness relain financial or account information on individual customers. but does not reEin Social
Security Numbers or insurance informadon? {Ermples of this risk include mercantile service or mercantile risks that do nol
capture Social Security Numbers.)
Does the appticant's busrness pnmarity keep non-public, personally identifying informadon related to their own
Ll Yes
f] ves
No
va<
Nd
N6
T-t
employees
Ft v".
only? (Examples of this risk Include servEe or mercantile risks lhat do not retain financial or account information lor
No
individual cuslomers.)
REMARKgEXPLANATIONS
Policy Information
Location Information
Location Number:
Proposal started:
11
lO4l2O15
and any
STATEMENT: tdectare the racts stated in this application to be true to the best ol my knowledg and requesl the company io issue thisinsurance
or another person liles an
.enewats thereof in .etiance rhereon. I ru.lhs unde6;;O rtrai; iLy p.rson *no rnowinqly and wilh the intnt to detraud any insUnce comPanv
puPose ol miaEading omation conceminq any fact
aDDtica on tor insu.ance or srare-ent ot .r.,m conuining any maG;;[y blse informa d. or conceals tor the
th;rb. commits a fraudulnt act, which is a crime and subieds the Pe6on to riminal and civil pnalts'
AppltcaNT.s
rN
iii,i'jii.-i-Jiiiiii,i'ii"|ne.powe'ot'uost'rutionano-rel;c;tion|o;ach.lovo|easprxyata||heeln9s;lhe
;;;;;a;;ff ;;;i;;.""0 Lv a ."rouv ot saio ano,neys and proxies so presn!. but itonly one is present.
Proxy
5s216 (12-12)
&
Rupp
and each or
lhen
Signed?
E Yes n
No
Page
3 ol4
1cJwsh621
Adobe Documenl cloud Transaclion Numbr CBJcHBcAABAAwBmgwOXvBPvodITQ
sv!
POLICY INFORMATION
N
HABITATIONAL INFORTIATIOI{
ls there a pool on premises?
ls the poolfenced?
ls there a divino board?
ls there a slide?
55216 (12.12)
Document Integrity
Page
4 ol4
13,000,000
General Aggregate
13,000,000
11,{no,oo{,
5t,ooo,0o0
Each Occurrence
Damage to Premises Rented to You (An,
One Premises)
J300,000
PD
BI
SPLIT LIMITS
SINGLE LIMITS
110.000
E Yes trNo
CGL Plus:
CLASSIFICAT'ONS
Territory
Location
Premium Basis
Prern/Ops Rate
6 Unit(s)
Products/Co Rat
0.310
5.,150
DEVIA
OPTIONAL
Your Product
Premium Charge tor Each
Approved by
GENERAL INFORMATION
EXPLAIN ALL "YES'' RESPONSES FOR ALL PAsT, PRESENT
OR OISCONTINUED OPERATIONS
COMMENTS/EXPLANATIONS
Total Commercial General Liability Premium
Document Integrity
1320.00
Pagel
552ss O2 12)
Adob clo4menl cloud
ransadon Numbr
x
x
in the last
five years?
of
tventiggregate insured losses exceed tlOO billion during any year the Act is in ffect, then the federal government and
particitaiind United States insurers that have met their insurer deduclible shall noi be liable for payment of any portion
of the loss that exceeds $100 billion. In the event that aggregate insured losses exceed $100 billion annually, no
additional claims will be paid by the federal govemment or insurers. This formula is currently effective through December
31, 2020 unless extended.
In the event that your policy, the policy for which you have applied or our proposal includes a premium charge for this coverage,
your agency will idvise you as to amount of this premium or it will be shown on the proposal. This premium charge will also be
ihown sepirately on the Declarations page for current policies or on the Declarations page that you will receive after the policy is
|SSUeO.
For lines of insurance, other than Workers Compensation, to which the Terrorism Risk Insurance Act of 2002 (including
ensuing Congressional actions pursuant to the Act) applies, you may also reject coverage for certified acts of terrorism by
completing thJfollowing and attaching it to your Auto-Owners Insurance Group Company* application or for in-force business. by
submitting it to the company.
- REJECTION OF TERRORISM RISK INSURANCE COVERAGE
I hereby reject Coverage tor acts ol terronsm aS Oelneo In tne I errorlsm KlsK Insurance Ac( or zwz \rrrLruux rg Errsutr rV Lulgr c5rrvr rdr oLuul
pursuant to the Act;. Except as noted below, I understand that I will have no coverage for losses arising from acts ofterrorism as defined in
ihe AcL ln the event of an act of terrorism as defined in the Act, future policies may also include a government assessed terrorism loss nskspreading premium in accordance with the provisions ofthe Act. It coverage is provided for building{s) and contents located in Arizona.
Georgia,illinois, lowa, North Carolina and f\iorth Dakota, l will have fre coverage for such property following a certifed act of terrorism. lfcoverage"is provided for building(s), contents or property covered by an inland marine policy located in Missou/i and Wsconsin l will have fire
121231201s
Date
Auto-Owners InSurance Group includes: Auto-Owners lnsurance Company, Home-Owners lnSurance Company, Owners
Insurance Company, Property-owners Insurance company and southern-owners lnsurance company.
Page 1 of
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(? Documenl
Integrity
ec'lwsh621rsVu
Slgnature:
Emait: scottj@gmail.com
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