APPLICATION FORM STORAGE OPERATOR'S CONTRACT …

DH 61-05 (09-19)

Applicant’s Name and Address:

Total Number of Storage Facility Locations:

Partnership Insured is: Individual Corporation Other (LLP or REIT)

__________________________________________________

Total Number of Self-Storage Units Available for Rent: ____________________________________________

Management Software System Used: ___________________________________________________________

Is your management system capable of providing monthly reports of participating leases? Yes No

If you currently have an insurance or protection program that is being offered to customers, estimate the current

number of customers participating: #___________customers

What insurance company provides coverage for your business liability? _______________________________

Does your current policy provide coverage for Customer Goods Legal Liability? ________________________

What are the limits of your general liability coverage and your CGLL coverage? ________________________

Loss History: List and describe losses to customers property for the last 3 years – including dates, location, cause

and amount (attach separate sheet or loss run if necessary):

______________________________________________________________________________________________________________

Requested Effective Date of Policy : _________________

$2,500,000 $5,000,000

$2,500 $5,000 $10,000

Requested Coverage Limits:

Liability Occurrence Limits Options:

Liability Limits Per Storage Space:

Requested Deductible:

OR Per Occurrence: $2500 $5000 $10,000

$25,000 $100,000 $250,000

If an occurrence deductible is selected, then select an annual

deductible cap: The cap must be higher than the per occurrence

deductible.

Annual Deductible Cap Options: $25,000 $50,000

$100,000 $250,000

APPLICATION FORM STORAGE OPERATOR'S

CONTRACT LIABILITY POLICY

Page 1 of 4 This product is provided by Deans & Homer on behalf of Greenwich Insurance Company.

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

No Deductible/No Retention:

Phone Number: _________________________________

Fax Number: ___________________________________

Email Address:__________________________________

_______________________________________ _______________________________________ _______________________________________ _______________________________________

Storage Operator’s Contract Liability Policy – Facility Profile(s) (Complete for each location where coverage is requested. Attach Additional Pages if necessary)

Legal Entity Name (e.g. LLC):

Facility Name and Location:

_______________________________________________________________

_______________________________________________________________

Applicant’s Signature: ____________________________________ Date: _______________

No. of Storage Buildings: ______ No. of Enclosed/Lockable Spaces: ______ No. of Mobile Units: ____

Year Built: _______ Was Building converted from other use? Yes No Conversion Year: ______

Business/occupancies other than self-storage on premises? (If applicable, please describe) ___________________

__________________________________________________________________________________________

If the facility is in a wind area, then provide gage and wind resistance rating of roof:______________________

Legal Entity Name (e.g. LLC): _______________________________________________________________

Facility Name and Location: _______________________________________________________________

_______________________________________________________________

_______________________________________________________________

No. of Storage Buildings: ______ No. of Enclosed/Lockable Spaces: ______ No. of Mobile Units: ____

Year Built: _______ Was Building converted from other use? Yes No Conversion Year: ______

Business/occupancies other than self-storage on premises? (If applicable, please describe) ___________________

__________________________________________________________________________________________

If the facility is in a wind area, then provide gage and wind resistance rating of roof:______________________

DH 61-05 (09-19) Page 2 of 4 This product is provided by Deans & Homer on behalf of Greenwich 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.)

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.




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.

______________________________________________ Signature of Insured or Agent


Documents

APPLICATION FORM STORAGE OPERATOR'S CONTRACT …