John J. Grimaldi & Associates, Inc.

Community Association Quote Request Form Fields marked in red are required.
Requestor Information
First Name:
Last Name:
Email:
Community Association Name:
Condo, Coop or HOA:
Location:
Property Manager Name:
Management Company
Company Name:
Address 1:
Address 2:
City:
State:	NY
ZIP:
On-site Manager:
Phone:
Current Coverage Description
Name of Company:
Name of Agent:
Expiration Date:
Property Insurance Limits
Building:
Personal Property:
Loss of Income:
Property Insurance Deductible:
Liability Insurance Limits
General Liability:
D&O Liability:
Umbrella Liability:
Fidelity Bond Insurance Limit:
Boiler & Machinery Insurance Limit:
Worker's Compensation Insurance Annual Payroll
Clerical (8810):
Building-NOC (9028):
Owned Automobile Insurance Please list year, make, model & purchase price for each automobile or truck owned by the Association under Miscellaneous Information and Comments at the bottom of this form.
Liability Limit:
Deductibles
Comprehensive:
Collision:
STEP 4
General Information
Number of Buildings:
Number of Stories:
Number of Units:
Year Built:
Square Footage:
Construction Type:
% of Commercial Occupancy:
Number of Employees:
Number of Swimming Pools:
Click Yes or No for the following items:
24 Hour Security:	Yes No
Central Station Alarm System:	Yes No
Hard Wired Smoke Detectors:	Yes No
On-Site Maintenance Personnel:	Yes No
Fully Sprinklered:	Yes No
Swimming Pool
Diving Board:	Yes No
Lifeguard:	Yes No
Fenced:	Yes No
If the building(s) are more than 20 years old, have any of the major systems (i.e., heating, plumbing, electrical, etc.) been updated? If so, please describe what has been done and when.

Association's Federal Tax ID:
Documentation required to complete quote:
1) Bylaw Insurance Requirements. 2) 3 year Claim History.
Miscellaneous Information and Comments:

John J. Grimaldi & Associates, Inc.
137 Summer Street • Buffalo, NY • 14222 • 716-636-1355 • 1-800-500-1355 • Fax: 716-636-1350

Community Association Quote Request Form