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Association Quote for Agent/Broker



NEW BUSINESS SUBMISSION FORM


Association Name:*
Expiration Date:
If Quoting Mid-Term Why?:
Association Contact (for Inspection):
Association Mailing Address:
Association Premises Address (if too long attach address listing):
City:
State:
Zip Code:
County:
If Non-Renewal Why?:
Expiring Premium:
Quote Insurance as (choose from the drop down):
Style of Association (choose from the drop down):
Type of Construction(choose from the drop down):
How many buildings:
How many units:
How many stories above ground:
How many units are rented:
If New Construction, How many units are sold?:
If New Construction, How many units are occupied:
How many units in foreclosure or vacant:
Is there a maintenance program to check on the conditions of these vacant/forclosed units:
Give a brief description of maintenance program:
Basement:
Garage:
If garage what type(choose from the drop down):
Roof Pitch:
Age of Roofs:
Does the building have siding:
Roof Material:
Siding Type(choose from the drop down):
Siding Age:
Year Association was built:
If Converted, what year:
Amenities, please list all:
Commercial Units:
If yes to Commercial Units, list what they are:
If yes to Commercial Units, are they condo units or Secparate entity:
Square footage of Property or Unit or Current Insurable Value:


FIRE LIFE SAFETY SUPPLEMENT APPLICATION
THIS IS REQUIRED ON ANY MID-RISE(OVER 4 STORIES) AND HIGH RISES (OVER 10 STORIES)


Smoke Detectors in Common Areas:
Smoke Detectors in Units:
Emergency Lighting in Common Areas:
Fire Extingushers in Common Areas:
Fire Extingushers in Units:
Self Closers on Common Area Doors:
Self Closers on Unit Doors:
Minimum 2 Exits Per Unit:
Manual Pull Fire Alarm:
Automatic Fire Alarm:
Annunicator Panel:
Is the building sprinklered:
If yes to above, What percentage of building is sprinklered:
Standpipes:
Open Stairwells:
24 hour Doorman:
Closed Curcuit TV Monitoring:
Intercom:
Garage Sprinklered:
Garage Employee:
If Yes to Above, Now Many:
Gabrage Chutes Sprinklered:
Elevators:
If Yes to above, How Many Passanger:
If yes to Elevators, How Many Freight:
If Yes to Elevators, Elevator Recall:
Other:


LOSS RUNS ARE REQUIRED

BY SUBMITTING THIS INFORMATION YOU ARE AGREEING THAT THE INFORMATION ABOVE IS TRUE AND CORRECT TO THE BEST OF YOUR KNOWLEDGE.  BOUND ACCOUNTS WILL BE INSPECTED WITHIN THE FIRST 60 DAYS AN IF THE INFORMATION IS NOT ACCURATE, A MID-TERM CANCELLATION MAY BE ISSUED.


Contact Name:*
Contact Phone Number:*
Contact Email Address:*
CISA Contact if you have one.:
 

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This site is provided by CISA Insurance | Main Office - 2170 Point Boulevard, Elgin, IL 60123 | Phone: 847-870-7000 | Fax: 847-259-4487

| Wisconsin | 4230 N. Oakland #131, Shorewood, WI 53211 | Phone: 888-278-7195 | Fax: 847-259-4487