Real Estate Umbrella Program

Page 1


Application for Insurance & Purchasing Group Membership
CREPE Umbrella Program
BROKER INFORMATION




GENERAL INFORMATION










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ATTACHMENTS
Each application must also be accompanied by the following:
  • Schedule of locations and values, including a list of additional insureds
  • List of vehicles, along with their makes, models, and a note regarding whether they are registered commercially
  • 5 years of loss runs for General Liability, Auto Liability, and D&O
  • Sample Copy of Insurance provisions within your lease agreements with your current tenants
  • Sample Copy of Insurance provisions within your contracts used with service contractors, property managers, etc.






EXPIRING UMBRELLA
Carrier Umbrella/Limits Provided Annual Premium Expiration Date

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UNDERLYING INSURANCE
Carrier Limits Policy Term Premium
General Liability*
Auto Liability 
Employers Liability
Liquor Liability
D&O Liability
Garage Keepers Liability
*at least 1M per Occurrence / 2M Aggregate is required with a “per location” general aggregate limit “uncapped” or if “capped”, at a minimum of $10M
For any underlying GL policies

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PRIMARY EXPOSURE
Habitational
Commercial

Miscellaneous

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PROTECTION CLASS
Do any locations contain?



Do any locations contain any of the following Marine exposures?




Does applicant have any of the following prohibited exposures?



DIRECTORS & OFFICERS


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LIFE SAFETY




Page 7

SECURITY
Guard Service





MAINTENANCE
If subcontractors:
Subcontractors:

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TRANSFER OF RISK


If yes:
WAREHOUSE, STORAGE, OR INDUSTRIAL

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REAL ESTATE PROPERTY MANAGERS




$

Indicate the percent of the properties Applicant manages:
%
%
%






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VACANT LAND EXPOSURE
RESTAURANTS



POOLS


OWNED AUTOMOBILES
Number Usage Notes
PPTs
SUVs and non-commercial"pick-up" trucks
Light
Vehicles 0-10,000 lbs., 1-8 passenger vans, and commercial "pick-up" trucks
Medium
Vechicles 10,001-20,000 lbs. and 9-20 passenger vans
Livery (<14)
Livery vehicles that contain 14 or less passengers
Livery (15+)
Vehicles or shuttles that contain 15 or more passengers
Buses 20+
Limited to buses that contain more than 20 passengers
Other

Transportation Services Provided by Applicant:

Valet Service
Definitions: Takes possession of vehicle from owner, parks the vehicle, and the keys are retained.
If third party, does the applicant write contracts that:

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LEAD SUPPLEMENT

The following questions apply to all buildings built prior to 1978 with residential units OR occupancies that involve the care, custody, or control of children under the age of 12.  


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NOTICE TO APPLICANT

The Insurance Broker And Applicant Declare That To The Best Of Their Knowledge And Belief And Warrant That The Information And Statements Set Forth In This Application (Including The Supplemental Applications And Schedules) Are True. The Undersigned Further Declares That Any Occurrence Or Event Taking Place Prior To The Effective Date Of The Insurance Applied For Which May Render Inaccurate, Untrue, Or Incomplete Any Statement Made Will Immediately Be Reported In Writing To The Insurer And The Insurer May Withdraw Or Modify Any Outstanding Quotations and/or Authorization Or Agreement To Bind The Insurance. The Insurer Is Hereby Authorized, But Not Required, To Make Any Investigation And Inquiry In Connection With The Information, Statements And Disclosures Provided In This Application, The Decision Of The Insurer Not To Make Or To Limit Any Investigation Or Inquiry Shall Not Be Deemed A Waiver Of Any Rights By The Insurer And Shall Not Stop The Insurer From Relying On Any Statement In This Application In The Event The Policy Is Issued. Any Person Who Knowingly And With Intent To Defraud Any Insurance Company Or Other Person Files An Application For Insurance Containing False Information Concerning Any Material Fact Thereto, Or Conceals Information For The Purpose Of Misleading, Commits A Fraudulent Insurance Act, Which Is A Crime.


This LRO Real Estate & Hospitality Umbrella Insurance program has been organized as a purchasing group (Combined Real Estate Purchasing Enterprises) domiciled in Delaware, pursuant to legislations enacted by the U.S. Congress as the Federal Liability Risk Retention Act of 1986.  You automatically become a member of the purchasing group once your completed application has been approved, quoted and coverage has been bound.


Disclosure Regarding Shared Limits Members Do Not Share Limits And Each Member Is Provided With Its Own Policy &/Or EOI.


Disclosure Pursuant To Federal Law Regarding Purchasing Groups [U.S.C. 15 3901, Et Seq.] PG Is A “Purchasing Group,” As Defined Under Federal Law, Formed To Purchase Liability Insurance On A Group Basis For Its Members To Cover The Similar Or Related Liability Exposure(s) To Which The Members Of PG Are Exposed By Virtue Of Their Related, Similar, Or Common Business Or Service. Members Do Not Share Limits And Each Member Is Provided With Its Own Policy &/Or Evidence of Insurance.