Real Estate Umbrella Program

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Application for Insurance & Purchasing Group Membership

Bolton Street Real Estate Umbrella Program

BROKER INFORMATION

Broker Name

Contact Name

Email Address

Phone

GENERAL INFORMATION

Application Submitted by (email address)

Applicant Name

Mailing Street

City

State

Zip Code

Website

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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.

Schedule of locations with list of additional insureds (Use our template):

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 mangers, 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

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PRIMARY EXPOSURE

Habitational

# of apartment units:

# of condo/co-op units:

# of sponsor/investor units:

# of single family homes HOA/PUD/POA units:

Commercial

Retail/shopping cemter square footage:

Office square footage:

Warehouse/storage square footage:

Type of occupancy:

Light industrial square footage:

Upload rent roll for all of the above occupancies.

Miscellaneous

Insured's office square footage:

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VACANT LAND EXPOSURE

# of acres of vacant land:

Is the vacant land perimeter secured?

YesNo

How are the premises secured?

FencedSecuritySigns

Is there construction or development on the land; or plans for development in the near future ?

YesNo

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

Are any transportation services provided by the applicant?

YesNo

Please upload a schedule of vehicles:

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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.