THE BROWNSTONE PROGRAM
Underwriting Application
This application may be used for up to 3 buildings. Larger schedules must be submitted on a Commercial Acord form! Please use TAB key to navigate between fields.
Applicant	Applicant Information
	Named Insured
	Mailing Address Street Address Address Line 2 City State Zip
	Applicant Type Corp. Partnership Individual LLC Other If Other, Explain
	Contact Information Telephone Fax E-Mail
	Policy Dates From: mm/dd/yyyy To: mm/dd/yyyy
Broker	Broker Information (if applicable)
	Agent/Broker Name
	Agent/Broker Address Street Address Address Line 2 City State Zip
	Contact Information Telephone Fax E-Mail
	License Information License # Date
Policy Delivery
	Delivery Type Electronic (by e-mail) Paper (by mail) Policy Delivery E-Mail

Yes No SECTION 8 HOUSING? Yes No IF YES, # OF UNITS:

Legend: - Review Location - Edit Location - Delete Location - Location Is Not Completely Filled Out

Loc # Bld # Building Address   1 1

Please save location information before proceeding to the next step!

Liability	Liability Section
	Basic Information None $500,000/$1,000,000 $1,000,000/$1,000,000 $1,000,000/$2,000,000 $2,000,000/$2,000,000 $2,000,000/$4,000,000 Commercial General Liability Basic Broad Coverage Type $500,000 $1,000,000 $2,000,000 Personal Liability No Yes Personal Injury?
If Directors & Officers Liability is Included the D&O Supplemental Applications Needs to be Completed	Additional Coverage $1,000,000 Directors & Officers Liability $1,000,000 Non-Owned & Hired Auto Liability No Yes Lead Liability $25,000 $50,000 $100,000 $250,000 $500,000 $750,000 $1,000,000 Water Damage Legal Liability $2,500 $5,000 $10,000 WDLL Deductible
Commercial Crime
	Limit $5,000 $10,000 $25,000 $50,000 $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 $500,000 Fidelity/Employee Dishonesty
Prior Carrier	Prior Carrier Information - NEW PURCHASE? Yes No
	General Information Carrier Policy Expiration Date Annual Premium Limits Has Any Policy or Coverage Cancelled or Been Non-renewed During the Past 3 Years? Yes No (if yes, please describe)
Loss History	Loss History - Enter all claims for the Prior 3 Years OR CHECK HERE IF NONE
	Check Here if Currently with Brownstone Yes No (if so, loss records will be on file with agency) Has There Ever Been a Lead or Mold Claim(s) or Complaint? Yes No (if yes, describe below) Date of Occurrence Type/Description of Claim Date of Claim Amount Paid Amount Reserved Claim Status Open Closed Open Closed Open Closed Open Closed
Umbrella	Commercial Umbrella Coverage Supplement - Annual Policy Only
Note: This section must be completed in its entirety before binding coverage.	3 Years of Currently Valued Loss History Has the insured had any individual losses exceeding $100,000? Yes No If so, please provide Date of Loss: Amount Paid/Reserved: Has the insured had aggregate losses exceeding $50,000? Yes No Does the insured require and document certificates of insurance and hold harmless agreements favoring the insured from all commercial occupancies and contractors working on the premises? Yes No
	General Information Is the insured a housing project, section 8, or affordable housing? Yes No Does the insured receive a government subsidy of any kind? Yes No What % of receipts? Is the insured location owned by a housing authority? Yes No Fire Escapes? Yes No Smoke Detectors in Units? Yes No Sprinkler Type: None Full Partial Is there minimum of two means of egress from each floor? Yes No If yes, describe: # of Stairwells - Enclosed # of Stairwells - Open Is there a doorman or concierge? Yes No Is there a buzzer or intercom system? Yes No Are entry doors locked? Yes No Yes No Is there a roof door? Yes No Is it locked? Yes No Is it alarmed? Manual Pull Central Station Fire Alarm Type Is there a business automobile exposure? Yes No Describe:

Any person who knowingly and with intent to defraud any insurance company or another 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 subjects the person to criminal and (NY: substantial) Civil Penalties. *Not applicable in CO, HI, NE, OH, OK, OR, ME and VA. Insurance benefits may also be denied).

Delivery Information
	Send To: New Business Submission Renewal Submissions Your Name: Your E-Mail: Notes:

Please completely fill out all required information for locations labelled by before submitting the application!