Evanston Insurance Company
  Markel American Insurance Company
  Markel Insurance Company

		
APPLICATION FOR TENANT DISCRIMINATION LIABILITY INSURANCE POLICY
(Claims Made & Reported Form)
1.	Name of Applicant: 	
2.	Address: 	
		Street	City	State	Zip Code
3.	(a)	Contact Person: 	
	(b)	Address (if different from above): 	
4.	Telephone:		E-Mail: 	
5.	Number of Employees: Full time: _________  Part time: _________  Office: _________  Field or On Site: 	
6.	Applicant is:	[   ] Partnership/Joint Venture      [   ] Individual Proprietor      [   ] Corporation      [   ] Public Agency
		[   ] Other   Describe: 	
7.	If Corporation, state exact name: 	
8.	Number of years in business: 	
9.	Is the Applicant part of an affiliated group of entities?	[   ] Yes  [   ] No
	If Yes, describe: 	
		
10.	Financial Information: 
 Based on Financial data as of:	Current Yr(MM/YY)      /	PRIOR YR.(MM/YY)         /	
Total Assets:	  $	  $	
Current Assets:	  $	  $	
Current Liabilities:	  $	  $	
Total Revenues:	  $	  $	
Net Income (Loss):	  $	  $	
11.	Property Under Management: For which Applicant is Manager and/or Owner.
	(a)	Number of locations: 		
	(b)	Commercial:	Retail:	square feet 	 and	number of units 	
	Office:	square feet 	 and	number of units 	
	Industrial:	square feet 	 and	number of units 	
	(c)	Residential: 	Section 8:	number of units 	
				Other Government Assisted Rental:	number of units 	
				All Other Residential:	number of units 	
12.	Are all properties under management ADA compliant?	[   ] Yes   [   ] No
If No, what are the Applicant’s plans to bring them into compliance?	
	
13.	Are any units either adult-only or senior citizen, or restricted to any other protected classes?	[   ] Yes   [   ] No
	If Yes, describe: 	
		
14.	What are the Applicant’s procedures for handling residents’ complaints?	
	
15.	Employee turnover for the past three years. 	
16.	Are background checks conducted on all prospective employees?	[   ] Yes   [   ] No
17.	Do all employees receive training on Fair Housing laws?	[   ] Yes   [   ] No
18.	During the last five years, have there been any tenant discrimination claims or proceedings arising out of activities as property owner or property manager against the Applicant, or any of its principals, partners, owners, officers, directors, employees, managers, managing members, its predecessors, subsidiaries, affiliates, and/or against any other person or organization proposed for this insurance?	[   ] Yes   [   ] No
	If Yes, attach complete details including description of allegations, status of claim, amounts demanded or paid, date of claim, and action taken to prevent the same type of claim in the future.
19.	Is the Applicant or any principal, partner, owner, officer, director, employee, manager or managing member of the Applicant or any person(s) or organization(s) proposed for this insurance aware of any fact, circumstance, situation, incident or allegation of negligence or wrongdoing, which might afford grounds for any claim such as would fall under the proposed insurance?	[   ] Yes   [   ] No
	If Yes, provide details.	
		
20.	Has any insurer cancelled, rescinded, nonrenewed or declined any similar insurance for the Applicant, its predecessors, subsidiaries, affiliates and/or for any other person or organization proposed for this insurance in the last five years?	[   ] Yes   [   ] No
	If Yes, attach a copy of such insurer’s notice. 
21.	Previous Tenant Discrimination Liability Insurance:
Policy Period	Insurer	Limits of Liability	Deductible/Co-Insurance	Retro Date	
					
22.	Coverage Requested:  Limits ________________  Deductible ______________  Effective Date:_______________
23.	Attach a copy of the Applicant’s:
	(a)	Equal Housing Opportunity Statement.
	(b)	Standard residential rental/lease agreement.
* NOTICE TO APPLICANT: The coverage for which application is being made is limited to liability for only THOSE CLAIMS THAT ARE FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD AND REPORTED TO THE INSURER DURING THE POLICY PERIOD OR WITHIN 90 DAYS AFTER THE EXPIRATION OF THE POLICY PERIOD. 
Applicant warrants that its properties are in compliance with statutory and regulatory requirements for persons with physical disabilities, and that applicant has a policy of non-discrimination in renting of its premises.
REPRESENTATION: I/We represent that the information contained herein is true and that it shall be the basis of the policy of insurance and deemed incorporated therein, should the Company/Underwriters evidence its acceptance of this application by issuance of a policy. I/We authorize the release of claim information from any prior insurer to the underwriting manager, Company and/or affiliates thereof.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR 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.
			
Name of Applicant		Title (Officer, partner, etc.)
			
Signature of Applicant	Date
Name of Broker: 		Applicable Surplus Lines Tax payable in addition to 
				premium.
Address: 	

SIGNING this application does not bind the Applicant or the Insurer or the Underwriting Manager to complete the insurance, but one copy of this application will be attached to the policy, if issued.