Fillable AMATEUR SPORTS FACILITY APPLICATION (Philadelphia Insurance Companies)

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AMATEUR SPORTS FACILITY APPLICATION (Philadelphia Insurance Companies)

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AMATEUR SPORTS FACILITY APPLICATION
SUBMISSION REQUIREMENTS
•
Complete ACORD Applications
• Photographs (Inside and Outside of Sports Facility)
• Brochure
•
•
Currently valued insurance company loss runs for the current policy period plus (3) prior years
•
Copy of Waiver of Liability Used
Applicant Name:
Effective Date:
Annual Gross Revenues: $
Months of Operation:
None
$5,000
$10,000
$25,000 $50,000 $100,000 $1,000,000
Are there procedures in place to verify that individuals and parents carry their own health
insurance?
No
No
Risk Management Contact:
Risk Management’s Phone:
Risk Management’s Email:
UNDERWRITING INFORMATION
GENERAL INFORMATION
1.
Does the Applicant belong to any national, state, or local sports association?
Yes
No
If yes, please explain below.
2.
Does use of the sports facility require eligibility requirements?
Yes
No
3.
Does the Applicant or your staff trained/certified in CPR or first aid?
Yes
No
4.
Does the Applicant require a completed waiver from all who use the sports facility?
Yes
No
5.
Is parent’s signature required for minors?
Yes
No
6.
Does the Applicant have a written incident report procedure in place?
Yes
No
7.
Does the Applicant keep a log of all incidents?
Yes
No
8.
Does the Applicant have stated concussion protocol and/or guidelines?
Yes
No
If yes, please provide a copy.
9.
Are coaches/trainers employees?
Yes
No
10.
If no, do they furnish certificates of insurance?
Yes
No
11.
Does the Applicant require a facility rental agreement?
Yes
No
If yes:
Individuals
Leagues
Groups
12.
By law, what is the maximum capacity of the facility:
13.
Staff: Number of Full Time:
Number of Part Time:
14.
Staff: Number under 18 years old:
18-25 years old:
Over 25:
15.
Does the Applicant maintain a full-time security staff?
Yes
No
If yes, number of personnel devoted to security:
If yes, is security staff:
Employed
Sub-contracted
If sub-contracted, do they furnish a certificate of insurance?
Yes
No
• If Abuse coverage is requested a copy of the Applicant’s Sexual Abuse Prevention Policy is required
ACCOUNT INFORMATION
Participant Accident Coverage Limits Carried ( Per Accident)
If the Applicant does not have Participant Accident Coverage do they need a quote?
Amateur Sports Facility
Page 1 of 8
© 2018 Philadelphia Consolidated Holding Corp.
05/2018
Copy of Applicant’s Participant Accident Policy
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16.
Does the Applicant have equipment rentals?
Yes
No
If yes, who operates the rental operation: Applicant Sub-contractor
If sub-contractor, do they furnish a certificate of insurance?
Yes
No
17. Does the Applicant sponsor a team? If yes, explain:
Yes
No
If yes, are they members of a sanctioned league?
Yes
No
If yes, indicate sanctioning body:
18. Is spectator seating provided by your facility?
Yes
No
If yes, maximum seating capacity:
If yes, type of seating: Permanent Portable
If yes, type of seating: Wood Metal Concrete Other:
If yes, is there a barrier (net, glass, etc.) between field and seats?
Yes
No
If yes, are non-slip surface treads used on all stairs?
Yes
No
19. Does the Applicant have locker rooms?
Yes
No
If yes, are the rooms monitored?
Yes
No
20. Does the Applicant have shower rooms?
Yes
No
If yes, are they open to the public?
Yes
No
If yes, are non-slip surfaces used in the shower area?
Yes
No
21. Are parking lots & curbs maintained (cleared) during winter storms?
Yes
No
If yes, is it done by: Applicant Sub-contractor
22. When a storm occurs, is there a procedure in place to remove ice and snow from roof
immediately as to avoid roof collapse? If yes, please explain:
Yes
No
23. Does the Applicant operate a baby sitting service?
Yes
No
If yes, what is the maximum amount of time child is supervised:
If yes, what is the ratio of adults to children: to
24.
Yes
No
Does the Applicant have any inflatable, fabric or air supported structures such as, but not
limited to, bubbles or domes?
25. Yes No Does the insured have any Soccer goals?
If yes;
a. Yes No While on the field, are they secured / anchored to the ground?
If yes, how:
b. Yes No While in storage, are they secured to a structural section of the building?
If yes, how:
CONCUSSIONS - ATHLETICS
1.
Yes No
Does the Applicant have a written concussion awareness and management program in
place, and, where applicable, is it compliant with current state legislation?
If yes, does this include:
a. Understanding a concussion and the potential consequences of this injury? Yes No
b. Recognizing the signs and symptoms of a concussion or other closed head injury and
how to respond? Yes No
c. Learning about steps for returning to activity after a concussion? Yes No
d. Focusing on prevention and preparedness to help keep participants safe? Yes No
*A copy of written program is required upon binding.
2. Does the insured require all coaches, instructors, and officials to complete the online
Concussion Course offered by the Centers for Disease Control and Prevention? Yes No
3. a. Does the insured communicate and distribute education materials to participants and /
or parents / guardians of minors about the nature of risk of concussions, including but
not limited to how to recognize concussion symptoms, in written or electronic form? Yes No
b. Does the insured require the participants and / or parents / guardians of minors to
sign an acknowledgment that they have received and reviewed? Yes No
4. If a concussion is suspected, does the Applicant require the participant to leave the game
or practice immediately? Yes No
Amateur Sports Facility
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© 2018 Philadelphia Consolidated Holding Corp.
05/2018
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5.
Does the Applicant mandate that participants suspected of suffering a concussion can only
return after at least 24 hours and with written clearance from a licensed physician before
being allowed to return to play?
Yes No
6.
Does the Applicant utilize base line testing?
Yes No
7.
Does the Applicant currently utilize any concussion impact monitoring technology?
Yes No
If yes:
a.
Describe:
b.
Advise the name of the manufacturer:
c.
Advise who monitors the data:
Coaches
Employees
Volunteers
3
rd
Party
LIFE SAFETY
1.
Is exit emergency lighting provided?
Yes No
If yes, how often is it inspected:
2.
Are exit doors equipped with panic hardware?
Yes No
3.
Are exit doors ever chained or locked?
Yes No
4.
Is there a fire detection system (smoke/heat)?
Yes No
If yes, describe:
If yes, are there manual pull stations on premises?
Yes No
5.
Are there written emergency evacuation plans?
Yes No
6.
Are employees familiar with appropriate evacuation procedures?
Yes No
7.
Is smoking permitted on premises? If yes, describe:
Yes No
FOOD AND BEVERAGES
1.
Does the Applicant operate a concession stand?
Yes No
If yes, is it self-service?
Yes No
If yes, are there designated eating areas?
Yes No
If yes, cooking equipment is:
Electric
Gas
Propane
2.
Are there any grills and /or deep fryers on premises?
Yes No
If yes, are they equipped with hoods, automatic fire suppression systems and automatic
fuel shutoff controls?
Yes No
If yes, how often is the system cleaned:
ABUSE OR MOLESTATION
N/A
A COPY OF THE APPLICANT’S SEXUAL ABUSE PREVENTION POLICY IS REQUIRED
1.
Yes
No
Does the Applicant have a written policy specifically defining and prohibiting grooming
behaviors?
If yes:
a. Is this policy communicated and confirmed in writing to all employees, volunteers,
and/ or independent contractors that have access to children?
Yes
No
b.
Yes
No
Does the policy prohibit contact with minor participants outside of the Applicant’s
operations (including social media)?
If yes, please describe:
Comments:
Amateur Sports Facility
Page 3 of 8
© 2018 Philadelphia Consolidated Holding Corp.
05/2018
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EXPOSURE INFORMATION
ITEMIZED RECEIPTS PERCENTAGE RENTAL
Practice $ Youth League %
Competition $ Adult League %
Shows/Events $ Non-League Rental %
Parties $ Other: (Describe below) %
Pro Shop $
Food $
Beverages $ (Non-Alcohol)
$ (Alcohol)
Other $ (Describe Below)
TOTAL
$
Notes for this section:
2. Does the Applicant conduct documented sexual abuse awareness training for all of the
following that have access to children?
a. Employees Yes No
b. Volunteers Yes No
c. Independent Contractors Yes No
IF YES, PLEASE SUBMIT A WRITTEN COPY OF THE TRAINING DOCUMENT.
Comments:
3. Does the Applicant specifically train their hiring manager(s) with respect to detecting high
risk behaviors/ responses in the hiring process? Yes No
4. Does the Applicant perform criminal background checks for all:
a. Employees Yes No
b. Volunteers Yes No
c. Yes No Independent Contractors
Comments:
5. In addition to criminal history question(s), does the Applicant’s employment application(s)
for employees, volunteers, and independent contractors contain question(s) to elicit high
risk responses specific to child sexual abuse? Yes No
6.
Yes No
Does the Applicant allow any one-on-one opportunity between employees, volunteers and/
or independent contractors and the children they serve?
If yes, please describe:
7.
Yes No
Does the Applicant have any operations where employees, volunteers and/ or independent
contractors will be physically touching another person?
If yes, please describe:
8. Does the Applicant have formal sexual abuse reporting procedures in place for all players,
employees, volunteers and/ or independent contractors? Yes No
9. Yes No Has the Applicant ever had an incident which results in an allegation of sexual abuse?
If yes, please describe:
Amateur Sports Facility
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05/2018
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BATTING CAGES – Waiver and Release Required
How many:
Min. age requirement:
Annual Receipts: $
Manufacturer:
Mfg. age / speed recs. posted?
1. Clearly marked for right or left handed hitters?
2. Are home plates clearly marked?
3. Machine velocity checked or calibrated?
If yes, by whom:
4. Are records kept? Yes No For how long?
5. Are pitching machine settings able to be altered by hitters?
6. Helmet or other safety equipment required to be used by participants in cages?
7. Light or similar indicator when last ball has been pitched?
NUMBER, TYPE, AND SIZE OF COURTS / PLAYING FIELDS
Number Type Length X width = Sq. Ft.
Number Type Length X width = Sq. Ft.
Number Type Length X width = Sq. Ft.
Number Type Length X width = Sq. Ft.
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
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© 2018 Philadelphia Consolidated Holding Corp.
05/2018
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FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief
and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true
and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes
prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the
quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,
MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN
EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE 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 THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, PA, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: 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.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY 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 (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER
OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR
PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR
COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT
MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT 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.
APPLICABLE IN PENNSYLVANIA: ANY 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.
APPLICABLE IN NEW YORK: ANY 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 FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
_________________________
____________________________________
SIGNATURE DATE
SECTION TO BE COMP
LETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
Amateur Sports Facility
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© 2018 Philadelphia Consolidated Holding Corp.
05/2018
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.
CYBER SECURITY LIABILITY ENDORSEMENT – SUPPLEMENTAL
QUESTIONNAIRE
Name of Applicant:
Address of Applicant:
City: State: Zip:
Website: www:
Nature of Operations:
1. Annual sales or revenue: $
2. Does the Applicant collect, store or otherwise handle any Personally Identifiable Information (PII)
belonging to customers, clients, or other third parties, other than employees?
If yes, please indicate the types of Personally Identifiable Information held (check all that apply):
Yes No
a. Social Security Numbers, Bank or Other Financial Account Details, Driver’s License or
other State Identification Numbers
b. Non-public Medical or Healthcare Data, including Protected Health Information (PHI)
c. Credit or Debit Card Information
3. a. During the last three (3) years, has anyone alleged that the Applicant was responsible for
damage to their computer system(s) arising out of the operation of the Applicant’s computer
system(s)?
Yes No
b. During the last three (3) years, has anyone made a demand, claim, complaint, or filed a
lawsuit against the A
pplicant alleging invasion
or interference of rights of privacy or the
inappropriate disclosure of Personally Identifiable Information (PII)?
Yes No
c. During the last three (3) years, has the Applicant been the subject of an investigation or
action by any regulatory or administrative agency for privacy-related violations?
Yes No
d. Is the Applicant aware of any circumstance that could reasonably be anticipated to result in a
claim being made against them for the coverage being applied for?
Yes No
PI-CYBE-APP (11/16)
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FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge
and belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this
Application) are true and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information
in this Application changes prior to the effective date of the policy, the Applicant will notify the Company of such changes and the
Company may modify or withdraw the quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KNOWIN
GLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE 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 THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: 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.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY 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 (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER
OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR
PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR
COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT
MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT 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.
APPLICABLE IN NEW YORK: ANY 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 FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (PLEASE PRIN
T/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
____________________________________________________
SIGNATURE DATE
SECTION TO BE COMP
LETED BY THE PRODUCER/BROKER
/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
PI-CYBE-APP (11/16)
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AMATEUR SPORTS FACILITY APPLICATION (Philadelphia Insurance Companies)

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