Property Coverage Change Change Property Coverage NOTE: Due to the complexity of this form and need to upload documents, you may find it easier to input this information on a desktop computer or a larger screen. Step 1 of 4 25% Housing Authority or Insured Entity* Housing Authority or Insured Entity Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Your name* First Last Your email* Phone*Location InformationLocation name Tax ID* Location address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Property Manager* If the Property Manager is not the housing authority, please attach certificates and the property management agreement (upload available at end of form).Does the contract property Manager have Errors & Omissions / Tenant Discrimination insurance?* YES NO Is the property manager or contracted party(ies) contractually responsible for fair housing claims?* YES NO Entity InformationType of Entity* Wholly owned by housing authority Limited liability company or partnership (general or limited) that provides affordable housing and is affiliated* with a housing authority or nonprofit corporation that provides affordable housing Non-profit corporation *Affiliated means (i) an ownership interest by the housing authority or nonprofit corporation in the partnership or LLC, (ii) the right of the housing authority or nonprofit corporation to direct management or policies of the partnership or LLC or (iii) a contract for the housing authority or nonprofit corporation to lease, manage or operate the affordable housing.What activities other than housing is the owner involved in?*Are you seeking insurance for these other activities?* YES NO If a non-profit corporation, do the nonprofit and the housing authority have the same board of directors?* YES NO Type of Unit(s) Senior Family HOA / Condo Single-Room-Occupancy Group Home Assisted Living / Disabled Supportive Housing Other Please describe services*Insurance InformationPolicies Requested* Liability & Property Liability Only Liability Only (During Construction) Property only Proposed effective date* MM slash DD slash YYYY Current deductible* General liability limits* Excess* Building / Structure InformationBuilding* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Year built*# of Stories*# of Dwelling Units*# of Non-dwelling Units*Building Sq Ft.*Building Structure Value* Building Contents Value* Annual Building Rents* Total structure value*Value per square foot*Dwelling type* Apartments Condos Duplex Triplex Are there NON-cosmetic repairs needed?* YES NO Describe non-cosmetic repairs that are necessary:Is the structure currently occupied?* YES NO Is the property on historical register?* YES NO Construction Type* Wood Fire Resistant Joisted Masonry Roof Type* Composit Metal Clay / Concrete Tiles Asphalt Shingles Stone-coated Steel Slate Rubber Slate Green Roof Built-up Roofing Roof last update (year)* Electrical last update (year)* Plumbing last update (year)* Heating last update (year)* Electrical Panel Box* Fuses Circuit Breakers Smoke detectors?* YES NO Sprinklers?* YES NO Fire alarms?* YES NO Monitored?* YES NO Does each unit have its own breaker/fuse box?* YES NO Management on site?* YES NO Maintenance equipment or buildings on site?* YES NO Playground?* YES NO Workout room?* YES NO If YES, are signs posted (i.e. “Use equipment at your own risk”)? YES NO Swimming pool?** YES NO If YES, does it have a 6’ fence & self-closing & latching gates? YES NO Are solar panels at this location?* YES NO If YES, what is the value? Organizational InformationHave Fair Housing complaints, claims/orders been filed against the entity?* YES NO Have building inspectors, the fire department, or a municipality issued building or life safety code violations, citations, or orders against the property?* YES NO When was the last fair housing training for all staff? MM slash DD slash YYYY Do you provide security services?* YES NO If YES, what type? Are any employees required to carry a special license of any kind?* YES NO If YES, what type? Attach photographs of the Building/PropertyIf there are any supporting photographs of the building interior or exterior, please attach. (supported formats: .jpg, .jpeg, .png, .hei; 12MB max per photo) Drop files here or Select files Accepted file types: jpg, jpeg, png, heic, Max. file size: 12 MB, Max. files: 25. Attach supporting documentsIf there are any supporting documents, please attach. (supported formats: .doc, .docx, .pdf) Drop files here or Select files Accepted file types: doc, docx, pdf, Max. file size: 128 MB. ELECTRONIC SIGNATURE* I certify that the information on the application is true and accurate to the best of my knowledge. I understand that if alternate information becomes available, it may result in a change of premium or policy/coverage cancellation. By submitting I am providing my electronic signature. CAPTCHAEmailThis field is for validation purposes and should be left unchanged.