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brstaztlra) TAILoRED pRorEcloN poLtcy AppLtcATtoN

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Transaction number:
Policy numberl
AO customer number:
Balling Account Number:
ProposallD: OrchardTo$rnHomeAss
oTPP-l378587

POLICY INFORITIATION

Date

AgencyCode: 43-0169-00
Agency/Address:

lssue Bound

X ProDosal

12/23/2015

Date:

Policy Effective

INSURE PRO LLC

TORY J WILCOX
12894 S PONY EXPRESS RD STE
DRAPER, UT 84020-8333
Phone: (801) 505.9950

Rewrite

12/21t2o15 |

ot

Policy

Term:

D(

Annual

3-Year (tidelity only)

2OO

insure@insurepro.biz

Producer Code:

Company:

01 -

Auto-Owners i

03 -

Home-Owners

l04-Owners

05 -

Property-Owners

08- Southern-Owners

Billlno lnlolmatlon
ADD

ro

CURRENT arLLrNG

ACCOUNT:

L_l

yes

lfyes. biling account number

L_.1 No

Blllln9 Optlons:

n
n

Asency
Escrcw

Dcposlt

Bin !
Pay n

rurteay

semr

Mdnod:

Alt.rn.t. Bllllng

Nam

nnual

[:pay
E o,"n"'v

Ma

! c-ast'

! ct'ecr

AulofiBiic Paymenls?

Monthly

credit

card

Insurcd Copy of Pohcy io /ency?

checkins/Savings

EFI !

! ves
n Yes

D lo
!ruo

egency Sweep

.nd Addr63:

APPLICATION INCLUDES THE FOLLOWING COVERAGE PARTS

Property Xl General

Liability Cnme

Inland

Marine

Other (please describe):

APPLICANT INFORMATION
Aoolicanti Orchard Town Home Association

l,4ailing

Entity: Association

Email:

Address: C/O Name: Scotl Jones

365 W 800 N
LtNDON. UT 84042.1337

Phone Number: (801)

FEINI
DescriDtion of Business ODerations:

Year business

PUD/HOA Assoc

started: o1lo1l2o14

Exclude Tenorism Coverage:

(New

venture: Yes x No lfyes, please provide description

ofowne/s expeience.)

NO

INSPECTION CONTACT

AUDIT CONTACT

Namer Scott Jones

Name: Scott Joncs

Address: 365 W 800 N

LINDON. UT 8iflx2-1337

Address: 355 W E00 N

L|NDON. UT 84042n$7

Email:

Email:

Phone: (801) 602.7050

Phone: (801) 602-7050

Accountrng Firm:

55216 (12-12)

Document Integrity

adob6 Docunrsntcloud Transaction Number

602-7050

PREMISES INFORMATION
Wnhan
LOC

Class Descraption

Program

Bldg

Crty
Lamils

32 - Apartment

365 W 800 N
L|NDON, UT 84042-1337

PREIIIUM MODIFICATION
cumulative i,4ulti-Policy Discount (Provide policy numbrs of other Auto-Owners policies. includinq Lffe & Disabiliq
Discor.:nt J
Policv Tvpe
Policv TvDe
Policv Number

Policy

Number

DE!9!1!L

o/.

'/o

Cumulalive Multi-Polcy Discount:

SpecialRating

Plan:_o/o

G.oup Name and Number:

Explain how Group membership was verified:

o/o

Experience Rating Plan

Commercial Busrness Tier Conf irmation:

IndividualRiskPremiuml/loditicationFaclor
Coverage Part

Approvedbyi
CrediUDebit

Coverage Part

CrediVDebit

Merit Rating Plan

Year Business Started: 2014

Prior

Losses. 0
Prior Canier Premium

0%

Medt Ratng:

PRIOR CARRIER INFORiIATION

Coverage Parts

Prior Canier

Prior carriers annual totalexpiring premium (includesr Property, General Liability. Inland Marine and crime):
Has there been continuous coverage for the past three

years?

l Yes

L-.1 No

Prior carrier Comments:

No prior common ground policy just forming the association

LOSS HISTORY
CHECK HERE IF NONE: IX

LOSS HISToRY ATTACHED:

fl

Wll verifiable loss informalion be

ENTER ALL CLAIMS (REGARDLESS OF FAULT) FOR THE PRIOR 3 YEARS

weather Related
Descriplion of occurrencey'Claim
Date o{ Loss
Line

Y/N

submitEd?

! ves ffi

t'to

Operr/

Closed

No Losses
What action hasthe applicant taken to prevent the type of losses lisled above from recurring?
Premium based on rates

effective:

s5216 (12-12)

C? Documeni Integrity

'10/25i'20'15

Paqe

ol 4

Adob Oo.ument c oud Transaction Numbsr CBJCHBCMBMWBmgumOXVBlpv0dlTQlec!wsh62isvu

GENERAL INFORMATION
EXPLAIN ALL "YES' RESPONSES

1. ls the apdicant invofued in, or does lhe applicant have ownership in

any other business operations. or have locations not indicated on the
aodication?

2. was the applicant previously insured whh a non-standard canier?

3. Any past losses or claims relating to negligent hiring?

EXPLAIN ALL "YES'' RESPONSES

5- During the lastten years. has the applicant been convicted

of any degree of the crime ot arson?

6. Has the applicantfiled bankruptcy within the last ten years?

Any policy coverage declined. cancelled or non-renewed during

the prior 3 years? (Not valld in Mssouri)

Does the owner have coverage wdnen in an AuteowneE

Group program for a related business wih this being ont a
new localion of the same type of opetation?

Nonpayment?

4- Any past losses or claims reladng !o sexual abuse or molestation

allegation3 or discdminalion?

fl

Underw ing Reasons?

n
x

REMARKS

OPTIONAL PROPERTY COVERAGES

Data Compromise Applied:
ls lhis applicant pnmarily engaged in any ofthe tollowing types of business?
Adrrtt Entertainment, Collecdon AgenE and Agencies, Credit Card or Financial Transaction Processing. Credit Reportjng
Agenchs, Data processors. Eduaalbnat Institutions, Financral Institutions, Gambling or Gaminq Eslablishments,
InformatiortData Erokers, Intormation Technology Outsourcing Companies or Municipalities

HospitEls,

informatron?

Does the applicant's business retain customers' Social Security Numbers and/or insurance
(Examples Of this risk include apartinents, doctor'S OffiCeS and professionalServices, such as attomeys Or accounte|nls

Does the applicant's busrness relain financial or account information on individual customers. but does not reEin Social
Security Numbers or insurance informadon? {Ermples of this risk include mercantile service or mercantile risks that do nol
capture Social Security Numbers.)
Does the appticant's busrness pnmarity keep non-public, personally identifying informadon related to their own

Ll Yes

f] ves

No

va<

Nd

N6

T-t

employees

Ft v".

only? (Examples of this risk Include servEe or mercantile risks lhat do not retain financial or account information lor

No

individual cuslomers.)

REMARKgEXPLANATIONS

Policy Information
Location Information
Location Number:

ls the applicant the Building Owner at this location? Yes

ls any space leased at this location? No

Proposal started:

11

lO4l2O15

and any
STATEMENT: tdectare the racts stated in this application to be true to the best ol my knowledg and requesl the company io issue thisinsurance
or another person liles an
.enewats thereof in .etiance rhereon. I ru.lhs unde6;;O rtrai; iLy p.rson *no rnowinqly and wilh the intnt to detraud any insUnce comPanv
puPose ol miaEading omation conceminq any fact
aDDtica on tor insu.ance or srare-ent ot .r.,m conuining any maG;;[y blse informa d. or conceals tor the
th;rb. commits a fraudulnt act, which is a crime and subieds the Pe6on to riminal and civil pnalts'

AppltcaNT.s

pRoxy DEstGNAlON (AUTo-owNERs tNsuRANcE co. oNLy) (NoT AppLrcAElE

rN

roWA) I desqnate J.F. Haiiold J S Tagsold ald

iii,i'jii.-i-Jiiiiii,i'ii"|ne.powe'ot'uost'rutionano-rel;c;tion|o;ach.lovo|easprxyata||heeln9s;lhe
;;;;;a;;ff ;;;i;;.""0 Lv a ."rouv ot saio ano,neys and proxies so presn!. but itonly one is present.
Proxy

5s216 (12-12)

&

Document Integrity verilied

Rupp

and each or

lhen

then that one shall have tullpower ro act

Signed?

E Yes n

No

Page

3 ol4

1cJwsh621
Adobe Documenl cloud Transaclion Numbr CBJcHBcAABAAwBmgwOXvBPvodITQ

sv!

POLICY INFORMATION
N

How many years of ownership or management experience in a similar business operation?

New Assgc

Age of oldest Building?

Has the roof, electrical, plumbing and heating systems been updated by a licensed contractor?

ls any building vacant?

ls there commercial cooking (a deep fat frye. or grill) in use?

HABITATIONAL INFORTIATIOI{
ls there a pool on premises?

ls the poolfenced?
ls there a divino board?
ls there a slide?

Are pool depths clearly marked on the pool?

ls this a dwelling converted into apartments?

55216 (12.12)

Document Integrity

Page

4 ol4

Adobs Document Cloud Transaclron Number: CSJCHBC ABMwBmgumOXv&PyodlTQlscJ$h621isvu

COMMERCIAL GENERAL LIABILITY SECTION

General Aggregate

13,000,000

General Aggregate

Products/Completed Operations Aggregate

Pe6onal Injury and Advertising Injury
Each Occunence
Damage lo Premises Rented to You (Any
One Premises)

13,000,000
11,{no,oo{,

Products/Completed operations Aggregate

Personal Injury and Advertising Injury

5t,ooo,0o0

Each Occurrence
Damage to Premises Rented to You (An,
One Premises)

J300,000

Medical Payments (Any One Person)

PD

BI

SPLIT LIMITS

SINGLE LIMITS

Medical Payments (Any One Person)

110.000

E Yes trNo

CGL Plus:

CLASSIFICAT'ONS
Territory

class Code and DescriDtion

Location

68500 Townhouses or Similar

Associatlons (Association Risk
Only) - Excluding Restaurant
or Drugstore Operations,
wines or Liqugrs

'A" Rate Deviated?

Premium Basis

Prern/Ops Rate

6 Unit(s)

Products/Co Rat
0.310

5.,150

DEVIA

OPTIONAL

ENDORSEMEI{TS AND RATING INFORIIIATION

Fungi or Bacteria Exclusion: Yes

ADDITIONAL INSURED/CERTIFICATE RECIPIENT

Form name and number:
Name
Location of Premises
Part leased to you

Your Product
Premium Charge tor Each

Approved by

GENERAL INFORMATION
EXPLAIN ALL "YES'' RESPONSES FOR ALL PAsT, PRESENT
OR OISCONTINUED OPERATIONS

6. Have any crimes occuned or been attempted

last the years?

1. Any operalions invofung storing, trealing, discharging,

applyirE, disposing or transponing ot hazardous material?
(e.q. landfills, wastes. fueltant6, etc.)?
2. Any operations sold, acquked or discontinued

9. Does the applicant own or operate any tanning beds or booths?

4. Are day care tacilites provided?

COMMENTS/EXPLANATIONS
Total Commercial General Liability Premium

Document Integrity

1320.00

Pagel

552ss O2 12)
Adob clo4menl cloud

ransadon Numbr

x
x

8. ls the applicant involved to any extent in hydraulic fracturing?

or from other employers?

5. Any Special Events sponsored?

on your premiss wilhin the

7, Ooes the aoDlicant manufaciule, insl,all, service ordemonstrate any

products?

in the last

five years?

3. Any leasing of employees to

EXPLAIN ALL'YES'' RESPONSES FORALL PAsT, PRESENTOR

OISCONTINUED OPERATIONS

of

IMPORTANT INFORMATION REGARDING TERRORISM RISK INSURANCE COVERAGE

and
REJECTION OF TERRORISM RISK INSURANCE COVERAGE
The Terrorism Risk Insurance Act of 2002 was signed into law November 26, 2002. The Act (including ensuing Congressional
actions pursuant to the Act) defines an act of terrorism, to mean any act that is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security and the Attorney General of the United States to be (i) an act of terrorism; (ii) to
be a violent act or an act that is dangerous to human life, property or infrastructure; (iii) to have resulted in damage within the
United States or outside the United States in the case of certain air carriers or vessels or the premises of a United States mission;
and (iv) to have been committed by an individual or individuals, as pan of an effort to coerce the civilian population of the United
States or to influence the policy or affect the conduct of the United States government by coercaon.
Subject to policy terms and conditions, the policy for which you have applied with an Auto-Owners Insurance Group Company*
provides insurance coverage for acts of terrorism as defined in the Act.
Any coverage for certain commercial lines of property and casualty insurance provided by such policy for losses caused by cenified acts of ierrorism are partially paid by the federal government under a formula established by federal law. Under this formula,
the government will reimburse us for 85yo of such covered losses that exceed the statutory deductible paid by us. However, beginning January 1 , 2016 the share will decrease 1% per calendar year until it equals 80%. You should also know that in the

tventiggregate insured losses exceed tlOO billion during any year the Act is in ffect, then the federal government and
particitaiind United States insurers that have met their insurer deduclible shall noi be liable for payment of any portion
of the loss that exceeds $100 billion. In the event that aggregate insured losses exceed $100 billion annually, no
additional claims will be paid by the federal govemment or insurers. This formula is currently effective through December
31, 2020 unless extended.

In the event that your policy, the policy for which you have applied or our proposal includes a premium charge for this coverage,
your agency will idvise you as to amount of this premium or it will be shown on the proposal. This premium charge will also be
ihown sepirately on the Declarations page for current policies or on the Declarations page that you will receive after the policy is
|SSUeO.

For lines of insurance, other than Workers Compensation, to which the Terrorism Risk Insurance Act of 2002 (including
ensuing Congressional actions pursuant to the Act) applies, you may also reject coverage for certified acts of terrorism by
completing thJfollowing and attaching it to your Auto-Owners Insurance Group Company* application or for in-force business. by
submitting it to the company.
- REJECTION OF TERRORISM RISK INSURANCE COVERAGE
I hereby reject Coverage tor acts ol terronsm aS Oelneo In tne I errorlsm KlsK Insurance Ac( or zwz \rrrLruux rg Errsutr rV Lulgr c5rrvr rdr oLuul
pursuant to the Act;. Except as noted below, I understand that I will have no coverage for losses arising from acts ofterrorism as defined in
ihe AcL ln the event of an act of terrorism as defined in the Act, future policies may also include a government assessed terrorism loss nskspreading premium in accordance with the provisions ofthe Act. It coverage is provided for building{s) and contents located in Arizona.
Georgia,illinois, lowa, North Carolina and f\iorth Dakota, l will have fre coverage for such property following a certifed act of terrorism. lfcoverage"is provided for building(s), contents or property covered by an inland marine policy located in Missou/i and Wsconsin l will have fire

Sionature - First Named lnsured orAuthorized Officer

121231201s
Date

Policy Number (if applicable)

INSURE PRO LLC

43-0169-00
Print Name

Agency Name and Agency Code

Auto-Owners InSurance Group includes: Auto-Owners lnsurance Company, Home-Owners lnSurance Company, Owners
Insurance Company, Property-owners Insurance company and southern-owners lnsurance company.

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ec'lwsh621rsVu

Slgnature:

Emait: scottj@gmail.com

Document Integrity Verifed

Ooqlmnt Cloud Transaclim Numbrr CBJCHAO\ABAAsBmgumOXvBrpy0dlTQl.c.ftsi62l

lsvu