APPLICATION Planned Unit Development Policy (P.U.D.) · PUD 09/2019 The product is provided by Deans & Homer on behalf of Riverport Insurance Company, Aspen American Insurance Company,

PUD 09/2019 Cover PageThe product is provided by Deans & Homer on behalf of Riverport Insurance Company, Aspen American Insurance Company, Mitsui Sumitomo Insurance Company of America, and Sirius America Insurance Company. Deans & Homer CA License # 0300517. Please visit us at www.deanshomer.com for list of other licenses.

APPLICATION

Planned Unit Development Policy (P.U.D.)

The following risks are not eligible for the Planned Unit Development Policy (P.U.D.). Additional restrictions may apply to certain risks not listed as ineligible below.

Risks Ineligible for the Planned Unit Development Program

• Condominiums, apartments, timeshares, and other residentialdwellings

• Clubhouses without smoke detectors

• Marinas or dams

• Mobile homes, trailers, and RV parks

• Tanning beds that are owned, operated, or maintained by theinsured

Risks Ineligible for Liability Coverage

• Aircraft (including drones and/or unmanned aircraft),airports, or landing strips

• Bridges over publicly accessible roads or trails

• Bridges 100 feet or more in length

• Daycares

• Retirement communities with assisted living or nursingfacilities.

• Riding amenities, saddle animals, or any other equestrianactivities

• Skiing, snowmobiling, or ice skating activities

• P.U.D. that owns and operates a golf course

• Water supplied for human consumption, except well-water.

• Hunting, archery, shooting, or firing ranges

• Armed guards or security dog services

• Passenger transportation services whether provided by theinsured or contracted to 3rd party.

• Skateboard parks• More than 50 RV parking spaces or storage units rented to

non-members.

• Valet services utilizing drivers under the age of 21

• Any commercial building maintained by the association that isleased to non-members, other than short-term rentals.

• Any P.U.D. that serves liquor, unless (a) liquor is provided free ofcharge, or (b) a certificate of insurance is provided naming theP.U.D. as additional insured

• Any P.U.D. with a developer or builder on the board of directors.

• Pools with a diving board or platform, lazy river, or slide are noteligible for liability coverage

• Bodies of water where the water is used for ice skating or waterskiing or by watercraft used for transport of passengers, sailboatsgreater than 10 feet in length, gasoline or diesel powered boatsexceeding 15 horsepower engine, or personal watercraft (e.g.,WaveRunner, Jet Ski, and Sea-Doo watercraft). Use of windsurfboards and kite surfboards are permitted.

• A body of water that has coastal or tidal beach(es).

ELIGIB ILITY

Agency Bill or Direct Bill

PUD 09/2019 The product is provided by Deans & Homer on behalf of Riverport Insurance Company, Aspen American Insurance Company, Mitsui Sumitomo Insurance Company of America, and Sirius America Insurance Company. Deans & Homer CA License # 0300517. Please visit us at www.deanshomer.com for list of other licenses.

Page 1 of 6

Application Date: ___________ Requested Inception Date: ___________ Requested Expiration Date: ___________

Producer Name: ______________________________________ Insured Name: _______________________________________ Address: ______________________________________ Mailing Address: _______________________________________

______________________________________ _______________________________________ Contact: ______________________________________ C/O: _______________________________________

Association Location (e.g. clubhouse or home within association) Property Manager Address: _______________________________________

_______________________________________ ________________________________________ Contact:

______________________________________ Name: ______________________________________ Address: ______________________________________ Contact:

Payment Options: Direct Bill Installment Options: Quarterly Semi-Annual Annual

Coverage Options: Property only Property+GL Property+GL+Crime

Minimum Premium: $500, except $750 in CA

History: Carrier Name Policy Period Premium* Cancellation/Non-Renewal dates and reasons *only for Prop.+GL+Crime

________________________ ___________ ____________ ________ _________________________________ ________________________ ___________ ____________ ________ _________________________________ ________________________ ___________ ____________ ________ _________________________________

Current Agent of Record _____________________________________

Property Coverage Section Deductible Structure and BPP $1,000 $2,500 $5,000 $10,000 $25,000 $100,000

EQSL$5,000 (no options)

(For additional structures, please complete and attach the Additional Information Addendum.)

Structure Descriptions Clubhouse Detached Office Building

Detached Storage or Service Building

Other Building:

Structure Value $ $ $ $ BPP Value $ $ $ $

Description

Square footage Construction type Year built Number of stories Year roof update Year electrical updated Year plumbing updated Type of roof Plumbing type Wiring on 100% circuit breakers? Percent of building sprinklered Distance from Fire Hydrant

Protection Class ________

Protective Systems: Burglar Alarm Fire/Smoke Alarm Carbon Monoxide Alarm Monitored Sprinkler System

APPLICATION

n/a n/a

Number of residences ________ Year community was established ____________

Is the HOA? A Master Association A Sub-Association Neither

$

% % % %

Subtotal

PUD 09/2019 Page 2 of 6

Increase Limits Total limit for all structures included in Policy

Clubhouse Detached Office Building

Detached Storage or Service Building

Detached Storage or Service Building

Accounts Receivable $5,000 $ $ n/a n/a Loss of business income $5,000 $ n/a n/a n/a

Extra expense $5,000 $ n/a n/a n/a Ordinance $250,000 $ $ $ $

Increased Limits for Additional Property & Losses Covered Limit included in Policy Option to increase:

Total Limit Requested Lawns, trees, shrubs and other plants per item $2,500, $10,000 total $

Money, checks, money orders, and stamps (no coverage for loss resulting from theft and mysterious disappearance)

$5,000 $

Property in transit $5,000 $

Property off premises $5,000 $

Valuable papers $5,000 $

Additional Structures Number of Structures Size Description Total Value of Structures

Pool # n/a $ Play Structures # n/a $ Athletic Courts # n/a $ Water treatment facilities, incl. pumping and storage equipment

# sqft List box: majority wood frame/other $

Permanently affixed seating structures (e.g. bus stop, benches, etc)

# $

Bridges # ft List box: majority wood frame/other $

Docks & Piers # sqft List box: majority wood frame/other $

Fences n/a ft long n/a $

Gates # n/a n/a $

Mailboxes # n/a n/a $

Signs/Monuments n/a n/a $

Lights/Poles # n/a n/a $

Sprinkler Systems # n/a n/a $

Streets n/a mi n/a $

Sidewalks n/a mi n/a $

Walls (non-retaining) # ft long n/a $

$

$

Other Features: If slope is in excess of 4%: _____ %

Optional Coverages - Property: Exclusion of Business Personal Property Earthquake Sprinkler Leakage (available only for structures exceeding a value of $100,000)

$

Other (list below):

Retaining Walls (up to $100k) n/a

The product is provided by Deans & Homer on behalf of Riverport Insurance Company, Aspen American Insurance Company, Mitsui Sumitomo Insurance Company of America, and Sirius America Insurance Company. Deans & Homer CA License # 0300517. Please visit us at www.deanshomer.com for list of other licenses.

Miscellaneous Structures Number of Structures Size Description Total Value of Structures

$

$

$

n/a

Subtotal

SubtotalGrand Total

PUD 09/2019 Page 3 of 6

Liabil ity Coverage Section Liability Limit requested:

$100,000/300,000 $300,000/1,000,000 $1,000,000/3,000,000 $2,000,000/4,000,000

$500,000/1,500,000 $3,000,000/4,000,000

Optional Coverages- Liability: l Non-Owned and Hired Auto Liability Coverage

Additional Insured: (not eligible: developers, contractors, builders)

Name: _________________________________ Address: _____________________________________________________

Description: _________________________________ _____________________________________________________

Complete the following only if applicable: (leave blank if not applicable)

Professional Property Manager Yes No Property management has office on site Yes No Maintenance personnel is on site daily Yes No

Frequently Occasionally/Incidental Never

Golf Course: If the golf course on P.U.D. premises is owned by the P.U.D. and leased to or operated by a different legal entity than the P.U.D., provide name of that legal entity: ___________________________________________________

Pools:

Outdoor pools and spas: Yes No Yes No

Indoor pools and spas: Yes No Yes No

are fenced at least 6 feet high have self-locking gates

have secured access have self-locking gates have surveillance cameras have regular security checks

Yes No Yes No

Swimming pool’s design and operation: Complies with the Virginia Graeme Baker Act Yes No Complies with federal, state and local government regulations Yes No

Yes No l Yes No

Indoor and outdoor pools and spas property signage and lighting meets ANSI standards Safety equipment (hooks and float) are readily available Written policies on supervision and maintenance are in place and enforced Yes No

Bodies of water other than pools:

Yes No Yes No

The body of water meets all the current safety standards Lake and beach access is permitted only to owners and owners’ guests Swimming areas are specifically designated or swimming is not permitted Yes No

The product is provided by Deans & Homer on behalf of Riverport Insurance Company, Aspen American Insurance Company, Mitsui Sumitomo Insurance Company of America, and Sirius America Insurance Company. Deans & Homer CA License # 0300517. Please visit us at www.deanshomer.com for list of other licenses.

Facility Rentals: Common facilities may be rented to non-members Does HOA lease land? Yes No If Yes, please describe:

P.U.D. Liability Features: Are pool(s) and spa(s) in the same fenced area? Yes No n/a

# of areas _______

# of separate pools _______ # of separate spas _____

Swim team: # of team members ______

Athletic courts: # _________

Green belts/parks: _________acre(s)

Open Space: _________acre(s) (undeveloped land, not intended for recreational use, e.g. hillside)

Property Management:

Community roads: ________ miles

Is the association financially responsible to maintain the roads? Yes No

Parking areas: # ____ sqft_______

Lakes with recreational use: _________acre(s)

Lakes/ponds not for recreational use: _________acre(s)

Inland beaches: # _________

Bridges less than 50 feet in length: # _________

Playgrounds: # _________

Litigation:HOA is or has been a party (plaintiff or defendant) in any pending or past litigation? Yes No If Yes, attach written explanation.

Claims:HOA is aware of a claim or circumstance which may or is likely to lead to a claim against the HOA? If Yes, attach written explanation. Yes No

n/a n/a

n/a n/a n/a n/a

n/a n/a

n/a n/a

n/a

n/a n/a n/a

PUD 09/2019

Crime-Employee Dishonesty Coverage

If optional coverage for Crime-Employee Dishonesty is requested, complete the below:

Number of P.U.D. employees with access to money or funds: _____

Limit requested: None $5,000 $10,000 $25,000 $50,000 $75,000 $100,000 $250,000 $500,000

Other requested Limit: ______________ (must be above $100,000 and in increments of $10,000, with a Maximum Total Limit of $500,000)

Deductible: policy deductible as selected for structures and BPP on page 2 applies

Page 4 of 6The product is provided by Deans & Homer on behalf of Riverport Insurance Company, Aspen American Insurance Company, Mitsui Sumitomo Insurance Company of America, and Sirius America Insurance Company. Deans & Homer CA License # 0300517. Please visit us at www.deanshomer.com for list of other licenses.

HOA Responsibilities

Is the HOA responsible for maintaining, repairing or insuring ANY portion of any residential structures?

Does the HOA have any responsibility for maintaining, repairing or insuring ANY portion of the homeowners' exclusive use area?

Is the HOA responsible for maintaining, repairing or insuring any front or backyards for any of the residential (homeowner) lots/parcels?

If you answered "Yes" to any of the above, please provide CCR's and explain:

Yes No

Yes No

Yes No

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Windstorm and Hail

$10,000 $25,000 $50,000 $100,000

Exclusion of Windstorm and Hail Coverage

Windstorm or Hail Roof Surfacing ACV Limitation

(Applicable in all states except AZ, CA, NM, NV, OR, UT and WA)

Increased Windstorm or Hail Deductible: None $75,000 $250,000

PUD 09/2019

Additional Information Addendum Structure Descriptions Clubhouse Detached Office

Building Detached Storage or Service Building

Other Building: Structure Value $ $ $ $

BPP Value $ $ $ $ Description n/a n/a Square footage Construction type Select Select Select Select Year built Number of stories Year roof updated Year electrical updated Year plumbing updated Type of roof Plumbing type Wiring on 100% circuit breakers? Percent of building sprinklered Distance from Fire Hydrant Protection Class

Increase Limits Total limit for all structures included in Policy Clubhouse Detached Office Detached Storage or Other

Accounts Receivable $5,000 $ $ n/a n/a

Loss of business income $5,000 $ n/a n/a n/a

Extra expense $5,000 $ n/a n/a n/a Ordinance $250,000 $ $ $ $

Building Service Building

The product is provided by Deans & Homer on behalf of Riverport Insurance Company, Aspen American Insurance Company, and Sirius America Insurance Company. Deans & Homer Licenses: AZ Lic# 29985 CA Lic# 0300517 NM Lic# 550802 NV Lic# 2834 OR Lic# 100151804 UT Lic# 3725 WA Lic#10579

The product is provided by Deans & Homer on behalf of Riverport Insurance Company, Aspen American Insurance Company, and Sirius America Insurance Company. Deans & Homer Licenses: AZ Lic# 29985 CA Lic# 0300517 NM Lic# 550802 NV Lic# 2834 OR Lic# 100151804 UT Lic# 3725 WA Lic#10579

Page 5 of 6The product is provided by Deans & Homer on behalf of Riverport Insurance Company, Aspen American Insurance Company, Mitsui Sumitomo Insurance Company of America, and Sirius America Insurance Company. Deans & Homer CA License # 0300517. Please visit us at www.deanshomer.com for list of other licenses.

% % % %

Attachments Required with Application submission

Provide all of the following:

• 5-year Currently Valued Loss History

• Site Plan

• Current Financial Statement, including Budget or Reserve Study

If applicable also provide:

• Business Personal Property Worksheet

• Schedule of landscaping and property maintenance equipment (include description, serial #,model #, and value)

• Schedule of fine arts property (include description and value)

• Certificate of liability naming the P.U.D. as additional insured if the P.U.D. owns land onwhich a golf course is located

• Annual receipts for

- Pools that are open to the public for a fee

- Tennis courts that are open to the public for a fee

- Golf courses that are not owned by the P.U.D. and open to the public for a fee

PUD 09/2019

Business Personal Property Value Worksheet State cost to replace with property of like kind and quality:

Clubhouse Detached Office

Detached Storage/ Service

Other Building:

________

Furniture and trade fixtures $ $ $ $

Office supplies, books, manuals and similar $ $ $ $

Computer equipment $ $ $ $

Alarm system components that are not permanently attached to the structure (and not included in computer equipment above)

$ $ $ $

Fire extinguishing equipment $ $ $ $

Janitorial supplies and equipment $ $ $ $

Recreational business personal property (e.g. sports or pool equipment)

$ $ $ $

Business personal property of others (not employees) $ $ $ $

Unscheduled equipment (e.g. maintenance equipment) $ $ $ $

Unscheduled fine art $ $ $ $ Other property:

$

$

$

$

$

$

$

$

$

$

$

$

Total: $ $ $ $

How are values determined? ____________________________________________________________________________

Date of last inventory: ______________

Add any additional relevant comments: ____________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

Page 6 of 6The product is provided by Deans & Homer on behalf of Riverport Insurance Company, Aspen American Insurance Company, Mitsui Sumitomo Insurance Company of America, and Sirius America Insurance Company. Deans & Homer CA License # 0300517. Please visit us at www.deanshomer.com for list of other licenses.

FRAUD WARNING: 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. (Not applicable in AK, AR, AZ, CA, CO, DE, DC, FL, ID, IN, KY, LA, MD, ME, MN, NH NJ, NM, NY, OH, OK, OR, PA, RI, TN, TX, WA and WV.)

FW 1.1

STATE FRAUD STATEMENTS

ALASKAAny person who knowingly and with intent to injure, defraud or deceive an insurance company files a claim containing false, incomplete or misleading information may be prosecuted under state law.

ARIZONAFor your protection Arizona state law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

ARKANSASAny 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.

CALIFORNIAFor your protection California law requires the following to appear on this form. Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

COLORADOFor your protection Colorado law requires the following to appear on this form. 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 agencies.

DELAWAREAny person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.

DISTRICT OF COLUMBIAWarning: It is a crime to provide false or misleading information to any 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.

FLORIDAAny 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 of the third degree.

IDAHOAny person who knowingly and with intent to injure, defraud or deceive any insurance company, files a statement containing any false, incomplete or misleading information is guilty of a felony.

INDIANAAny person who knowingly and with intent to defrauds an insurer files a statement of claim containing any false, incomplete or misleading information commits a felony.

KENTUCKYAny person who, knowingly and with intent to defraud any insurance company or other person, files a 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.

LOUISIANAAny 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.

MAINEIt 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.

PUD 09/2019

Provided by Deans & Homer on behalf of Riverport Insurance Company, Aspen American Insurance Company, Mitsui Sumitomo Insurance Company of America, and Sirius America Insurance Company. (Company depends upon the state).

Deans & Homer CA License #0300517. Please visit us at www.deanshomer.com for list of other licenses.

MARYLANDAny person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

MINNESOTAA person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

NEW HAMPSHIREAny person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

NEW JERSEYAny person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

NEW MEXICOAny 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.

NEW YORKAny 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 shall be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation.

OHIOAny 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.

OKLAHOMAWARNING: 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.

OREGONAny 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.

PENNSYLVANIAAny 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.

RHODE ISLANDAny 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.

TENNESSEEIt 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.

TEXASAny person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

VIRGINIAIt 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.

WASHINGTONIt is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

WEST VIRGINIAAny person who knowingly presents false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of crime and may be subject to fines and confinement in prison.

FW 1.2PUD 09/2019

Provided by Deans & Homer on behalf of Riverport Insurance Company, Aspen American Insurance Company, Mitsui Sumitomo Insurance Company of America, and Sirius America Insurance Company. (Company depends upon the state).

Deans & Homer CA License #0300517. Please visit us at www.deanshomer.com for list of other licenses.

Signature of Insured or Agent