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AURA UMBRELLA PROGRAM SUPPLEMENTAL APPLICATION

Agent/Broker Information:

Agency/Brokerage Name:	Phone #:
Contact Person:	E-mail Address:

Applicant Verification Details:

Applicant Name/Named Insured:

DBA or Trade Name (if any):

Insured’s Address (Can NOT be a PO Box):

City:	State:	Zip Code:
Main Phone:	Fax:

Website Address:

Date Business Started:

Annual Sales/Receipts:

Insured Information:

Please provide a brief description of all of the insured’s operations:
Additional Named Insureds: Please include list of Named Insureds as an attachment including description of operations
Is the First Named a:	LRO Real Estate Owner (Including Hotel/Motel)? ☐	Condo/Coop/HOA Assn? ☐	Real Estate Mgt. Co.? ☐

Policy Information:

Effective Date:				Expiration Date:
Limits Requested:	$5 Mill ☐	$10 Mill ☐	$15 Mill ☐	$20 Mill ☐	$25 Mill ☐	$50 Mill ☐	$75 Mill ☐	$100 Mill ☐

Expiring Insurance Information:

If New Business submission, expiring Lead Umbrella limits:		Expiring Annual Umbrella Premium:
If New Business submission, expiring Lead Umbrella Carrier :
If expiring carrier not input, please select reason why:	Carrier Unknown: ☐	NONE - There is no expiring umbrella: ☐
If Renewal to AURA, expiring Certificate/Member No.:

Insured Exposure Summary:

Total # of Locations:	Total # of Coop/Condo Units: (including # of homes for Homeowner Assns.)
Total # of Apartment Units:	Total # of 1 or 2 Family Dwelling Units:	Total # of Hotel/Motel Rooms:
Total Commercial Sq. Ft.:	Total # of Swimming Pools:	Total # of Golf Courses:
Total Acres Vacant Land:	Total Acres Land Leased:	Total # of Owned Autos:

Physical Exposures/Locations in New York State (Question #1 must be answered for all accounts and #2 & #3 if applicable):

1. Does the insured have physical exposures/locations in New York State? *(If NO, proceed onto next section)*	YES: ☐	NO: ☐
2. Do you require a signed contract in place for any third party contractor performing work on premises?	YES: ☐	NO: ☐
3. If YES to #2, does the contract contain hold harmless language, additional insured status for you and a minimum of $1,000,000 liability insurance requirements for the contractor?	YES: ☐	NO: ☐

PROGRAM INDUSTRY QUESTIONS

1. Does primary General Liability contain any sub-limits less than $1,000,000(other than Medical Payments or Fire Legal)?	YES: ☐	NO: ☐
2. Are all locations currently in compliance with all property statutes, local ordinances and building codes?	YES: ☐	NO: ☐
If NO, please explain:
3. Does the applicant have any of the following exposures?
a. Subsidized Housing:	YES: ☐	NO: ☐
If YES, are there any locations at which more than 30% of the units are subsidized?	YES: ☐	NO: ☐
b. Assisted Living Facilities:	YES: ☐	NO: ☐
c. Senior Housing:	YES: ☐	NO: ☐
If YES, are there any assisted living &/or Medical services provided at any of these locations?	YES: ☐	NO: ☐
d. Student Housing (Example: Dorms or locations that are solely rented out to students):	YES: ☐	NO: ☐
e. Mobile Homes, RV or Trailer Parks?	YES: ☐	NO: ☐
f. Enclosed Malls:	YES: ☐	NO: ☐
If YES, are there any enclosed malls that are 1,000,000 sq. ft. (building sq. ft.) or larger?	YES: ☐	NO: ☐
g. Marinas or boat docks/slips? If YES, (i.) number of slips?	YES: ☐	NO: ☐
If YES, Any fueling or repair operation?	YES: ☐	NO: ☐
h. Nightclubs:	YES: ☐	NO: ☐
*If YES to questions (5)b-h, please provide details:***
4. Does the applicant have any Armed Security Personnel?	YES: ☐	NO: ☐
If YES, are the armed guards employees of the applicant?	YES: ☐	NO: ☐
If NO, does the applicant require that the security service retain at least $1,000,000 liability coverage?	YES: ☐	NO: ☐
5. Are all buildings at least 70% occupied?	YES: ☐	NO: ☐
If NO, please provide reason(s) why any building(s) is/are not at least 70% occupied at the time of the proposed effective date:
(a) There are brand new construction &/or complete gut/renovation locations:	YES: ☐	NO: ☐
If brand new construction or a recent complete gut/rehab will all major construction operations be completed as of the proposed effective date (a temporary or final C.O. MUST have been issued and received)	YES: ☐	NO: ☐
(b) There are vacant buildings: If YES, which location(s):	YES: ☐	NO: ☐
(c) Other reasons (provide details):

AUTOMOBILE FLEET BREAKDOWN

Does the applicant have any Owned Autos? *(If NO, proceed onto next section)*			YES: ☐	NO: ☐
Type	# of Owned Units	Describe General Use
Private Passenger / SUV
Light Truck – GVW 10,000 lbs. or less (WITHOUT passenger transport)
Light Truck – GVW 10,000 lbs. or less (WITH passenger transport) (including 1–8 passenger vans)
Medium Truck – GVW 10,001-20,000 lbs. (WITHOUT passengers trans.)
Medium Truck – GVW 10,001-20,000 lbs. (WITH passenger transport) (including 9-20 passenger vans)
Heavy Truck (GVW 20,001-45,000 lbs.(units not for hire)

Extra Heavy Truck and Tractor/Short or Long Haul (GVW over 45,000 lbs.) (units not for hire)
Does the insured own/operate any other vehicle types not listed above? Including but not limited to: School Buses, Buses with passenger capacity greater than 20, Limousines, Taxis, Rapid Delivery Operations (i.e. pizza, newspaper, magazine, etc.), gasoline hauling, Waste/Red Label or Commodity II or IV hauling?			YES: ☐	NO: ☐

If any of the insured’s autos are registered or principally garaged in any of the following states, please specify all applicable states:
☐ None ☐ FL ☐ GA ☐ LA ☐ NH ☐ VT ☐ WV*
* If WV was selected, does the Insured currently carry at least $1,000,000 of UM/UIM primary limits for its WV auto exposures?	YES: ☐	NO: ☐

UNDERLYING COVERAGE INFORMATION

1. Is the GL policy written with an ISO Form CG0001 or equivalent?	YES: ☐	NO: ☐
2. Does the GL policy include Hired & Non-owned Auto Cov.?	YES: ☐	NO: ☐	If YES, H&NOA Limit $

3. Does the GL policy have a Per Location General Aggregate?

YES: ☐

NO: ☐

If YES, Per Location Limit? $

If YES, is the per location aggregate capped?

YES: ☐

NO: ☐

If YES, Cap Limit? $

Type	Carrier	Eff Date: (MM/DD/YY)	Exp. Date: (MM/DD/YY)	Policy Premium	Limits
Automobile Liability				$	Each Accident (CSL):	$

HIRED/NON-OWNED AUTO LIAB. ONLY

Separate HNO Limit (CSL):

- or -

Included in Gen. Liab. Limits

YES☐ NO☐

General Liability	$	Each Occurrence:	$
		General Aggregate:	$
		Products / Completed Operations Aggregate:	Excluded: ☐ Included: ☐ or $
		Advertising Injury / Personal Injury (Each Offense):	$
Employers Liability	$	Bodily Injury by Accident:	$
		BI by Disease (Each Employee):	$
		BI by Disease (Policy Limits):	$
Liquor Liability	$	Each Common Cause Limit: Each Occurrence: Aggregate Limit:	$ $ $
Employee Benefits Liability	$	Claims Made: Yes ☐ No ☐ If YES, retro date: Per Occurrence: Yes ☐ No ☐ Aggregate Limit:	$ $
Directors & Officers Liability *	$	Each Claim: Aggregate Limit:	$ $
* Only claims-made Directors & Offices Liability (D&O) policy forms for Not-for Profit Residential, Time-Share and Commercial Condominium Associations are to be scheduled on the umbrella policy. D&O policies for For-Profit organizations are not covered on the umbrella policy. D&O for Condominium Hotels are also not eligible.
Garage Keepers Legal Liability	$	Each Occurrence:	$
Other:	$		$
Other:	$		$

LOSS INFORMATION

Minimum of three (3) years currently valued hard copy underlying liability loss runs required.

General Liability:

For General Liability and Products Liability, in the last five (5) years, are you aware of aggregate incurred loss totaling of $500,000 or more?		YES: ☐			NO: ☐
For General Liability and Products Liability, have there been any individual incurred losses in excess of $250,000 in the past three (3) consecutive years?		YES: ☐			NO: ☐
Have there been any New York Labor Law claims in the last five (5) years?	N/A: Account does NOT have any NY exposures: ☐		YES: ☐	NO: ☐
Have there been any assault, rape or shooting claims the last five (5) years? If YES, please provide details:			YES: ☐	NO: ☐

Automobile Liability:

For Automobile Liability (if applicable), have there been any individual incurred losses in excess of $250,000 in the last three (3) consecutive years?	N/A: ☐	YES: ☐		NO: ☐
For Automobile Liability (if applicable) in the last five (5) years, are you aware of aggregate incurred loss totaling of $500,000 or more?	N/A: ☐	YES: ☐	NO: ☐

Condo/CO-OP/HOA/PUD Directors & Officers Liability:

For Directors and Officers Liability (if applicable) have there been any incurred losses in the last three (3) consecutive years?	N/A: ☐	YES: ☐	NO: ☐
If YES, please provide three (3) years currently valued loss runs (within six months of the proposed effective date)

New Purchases / New Construction:

If any required loss information is not available for the last three (3) consecutive years, please select a reason:
New Construction: ☐	New Purchase: ☐ Date of Purchase:	Other, please describe:

LOCATION DETAIL

Location #

Street Address:
City:		State:			Zip:

Rating Exposure: *(complete all that apply):*
Apartment Units:	Dwellings 1 or 2 Family:		Condo/Coop Units:	Timeshare Units:
HOA/PUD Units:	Hotel/Motel Rooms:		Retail LRO Sq Ft:	Restaurant LRO Sq Ft
Office LRO Sq Ft:	Office Occ by Insured Sq Ft:		Warehouse LRO Sq Ft*:	Industrial LRO Sq Ft*:
Manufacturing LRO Sq Ft*:	Parking Garage Sq. Ft (1):		Parking Lot Sq. Ft (2):	Acres of Vacant Land:
Acres Land Lease:	Golf Courses:		Describe type of lease (e.g. fast food restaurant, bank, etc.)
# of Swimming Pools:			Other Exposure – Describe type of exposure:

(1) Do not provide sq. ft. for a garage that is part of an insured shopping center or office building, etc.
(2) Only provide sq. ft. for a standalone lot which is not part of an insured shopping center or office building when the garage is for the exclusive use of the tenants and their guests/customers.

* Are there warehouse, industrial or manufacturing occupancies/tenants?	YES:☐	NO:☐
If YES, are any explosives, high-hazard chemicals or materials stored?	YES:☐	NO:☐

Is this location a Hotel or Motel? *(If NO, proceed onto next section)*	YES: ☐	NO: ☐
If YES, Are there any recreations other than swimming pools, spas, in-house health clubs, restaurants, or retail exposures in the hotels (Some examples would be tanning beds, health club/fitness centers open to the general public for a fee, lazy rivers, splash gardens, water parks, water slides, kids activities such as babysitting, day camps, etc)? IF YES, PROVIDE DETAILS:	YES: ☐	NO: ☐
Is there a restaurant on the Hotel or Motel premises?	YES: ☐	NO: ☐
If YES, are Automatic Extinguishing Systems in place?	YES: ☐	NO: ☐
If YES, are liquor receipts greater than 30% of the total restaurant receipts at each restaurant?	YES: ☐	NO: ☐

Construction / Fire / Life Safety:
Year Built:		# of Stories:		Total Building Sq. Ft.:
Fire Resistive: ☐	Masonry Non-Combustible: ☐		Non-Combustible: ☐		Joisted Masonry: ☐
Masonry/Brick Veneer: ☐	Frame: ☐		Other:

If building is over two (2) stories are there at least two means of egress per floor?					YES:☐		NO:☐		Building is under three (3) stories: ☐
Fully Sprinklered?	YES:☐		NO:☐	Partially Sprinklered?		YES:☐		NO:☐		If partial sprinklers, where?
Central Station Fire Alarm?	YES:☐	NO:☐		Emergency Lighting?		YES:☐		NO:☐
Smoke Detectors?	YES:☐	NO:☐		Other Fire/Life Safety Devices (describe):

SWIMMING POOL QUESTIONS:

Does this location have a Swimming Pool? *(If NO, proceed onto next section)*				YES: ☐		NO: ☐
Number of Swimming Pools:
Do any pools have a slide?	YES:☐	NO:☐	Slide Height? (required if there are slides)
Do any pools have a diving board?	YES:☐	NO:☐	Diving Board Height? (required if there are diving boards) (required if has slides) If partial sprinklers, where?
Are pools fenced and locked when closed?	YES:☐	NO:☐	Pool depths clearly marked?		YES:☐	NO:☐
Lifesaving equipment available?	YES:☐	NO:☐	Are pool rules clearly posted?		YES:☐	NO:☐
Are lights kept on during evening hours?	YES:☐	NO:☐	Lifeguard present during hours of operation?		YES:☐	NO:☐
Does the swimming pool meet federal and state safety requirements?	YES:☐	NO:☐

NOTICE TO APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR, CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.

NOTICE TO ARKANSAS APPLICANTS: “ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.”

NOTICE TO COLORADO APPLICANTS: “IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AUTHORITIES.”

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: “WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.”

NOTICE TO FLORIDA APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY IN THE THIRD DEGREE.”

NOTICE TO KENTUCKY APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.”

NOTICE TO LOUISIANA APPLICANTS: “ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.”

NOTICE TO MAINE APPLICANTS: “IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.”

NOTICE TO NEW JERSEY APPLICANTS: “ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.”

NOTICE TO NEW MEXICO APPLICANTS: “ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.”

NOTICE TO NEW YORK APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.”

NOTICE TO OHIO APPLICANTS: “ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.”

NOTICE TO OKLAHOMA APPLICANTS: “WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY.” (365:15-1-10, 36 §3613.1)

NOTICE TO PENNSYLVANIA APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.”

NOTICE TO TENNESSEE APPLICANTS: “IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.”

NOTICE TO VIRGINIA APPLICANTS: “IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.”

PLEASE READ THE FOLLOWING STATEMENT CAREFULLY AND SIGN BELOW WHERE INDICATED.

SIGNATURE PAGE

ALL WRITTEN STATEMENTS, AND SUPPLEMENTAL MATERIALS FURNISHED TO THE INSURER IN CONJUNCTION WITH THIS APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE A PART HEREOF.

THE UNDERSIGNED AUTHORIZED OFFICER OF THE APPLICANT, HAVING MADE DUE INQUIRY (INCLUDING BUT NOT LIMITED TO DUE INQUIRY OF THE LEGAL AND RISK MANAGEMENT DEPARTMENTS), DECLARES THAT TO THE BEST OF HIS KNOWLEDGE AND BELIEF THE STATEMENTS SET FORTH HEREIN OR ATTACHED HERETO ARE TRUE. THE UNDERSIGNED AUTHORIZED OFFICER AGREES THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION (INCLUDING INFORMATION PROVIDED BY ATTACHMENT HERETO) CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE EFFECTIVE DATE OF THE INSURANCE, HE/SHE (UNDERSIGNED) WILL, IN ORDER FOR THE INFORMATION TO BE ACCURATE ON THE EFFECTIVE DATE OF THE INSURANCE, IMMEDIATELY NOTIFY THE INSURER OF SUCH CHANGES, AND THE INSURER MAY WITHDRAW OR MODIFY ANY OUTSTANDING INDICATIONS, QUOTATIONS AND/OR AUTHORIZATIONS OR AGREEMENTS TO BIND THE INSURANCE.

THE UNDERSIGNED, ON BEHALF OF THE APPLICANT, AGREES THAT THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE INSURER TO COMPLETE THE INSURANCE, BUT IT IS AGREED THAT THIS APPLICATION SHALL BE THE BASIS OF ANY COVERAGE ISSUED BY US AND WILL BE ATTACHED TO AND BECOME PART OF THE POLICY.

Applicant/Named Insured:

Applicant: Broker/Agent:

Signature: Signature:

Print Name: Print Name:

Title: Title:

Date: Date:

AURA PROGRAM SUPPLEMENTAL APPLICATION

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