General Information

Policy Effective Date:

Name of the Insured Organization:

Address of the Insured Organization:

Street Address City State / Province / Region ZIP / Postal Code

Property Manager Information:

Name

First Last

Title

Telephone:

Fax:

E-Mail Address:

Loss History

During the last 5 years has the Insured Organization or any of its directors, officers, or employees been involved in any litigation that could have a material impact on the Insured Organization?

Yes

No

Prior Knowledge

Does anyone for whom insurance is sought have any knowledge or information of any act, error, omission, fact, or circumstance which may give rise to a Claim which may fall within the scope of the proposed insurance?

Yes

No