Community Underwriters 2385 NW Executive Center Drive Suite 100 Boca Raton, FL 33431
(All fields are required)
Potential Insured
Physical Address
Physical City
Physical State
Physical Zip Code
Mailing Address (c/o)
Mailing Address 2
Mailing City
Mailing State
Mailing Zip Code
Contact Person First Name
Contact Person Last Name
Phone Number for Insured
Email Address for Insured
Agency Name
Producer First Name
Producer Last Name
Agency Address
Agency City
Agency State
Agency Zip Code
Agent Phone
Agent Email
Type of Risk Apt./Hotel/Time Share
Number of Units
Year Built
FEIN#
Has insured been involved in any uninsured lawsuit in the past 5 years? --Select One--NoYes
Any complaints filed in the past 5 years against insured with any state/county/city or governmental Agency? --Select One--NoYes
Have you had any uninsured claims in the past 3 years? --Select One--NoYes
You are required to be insured for Commercial General Liability including Hired and Non Owned Auto Liability, Property Insurance including wind storm, and Workers' Compensation and coverage must be in place and active at time of claim
You are required to have in place and active Directors and officers insurance at time of claim
Check here if you understand and agree I agree
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 FLORIDA, A PERSON IS GUILTY OF THE THIRD DEGREE).
The undersigned states that he/she is an authorized representative of the applicant and declares to the best of his/her knowledge and belief and after reasonable inquiry, that the statements set forth in this application (and any attachments submitted with this application) are true and complete and may be relied upon by Company in quoting and issuing the policy. If any or the information in this Application changes prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the quote or binder
THIS APPLICATION WILL BECOME PART OF THE POLICY
**Hard copy to be forwarded to Agent for signature**
