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AMATEUR SPORTS LEAGUES/CAMPS/CLINICS RENEWAL SUPPLEMENT (Philadelphia Insurance Companies)

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AMATEUR SPORTS LEAGUES/CAMPS/CLINICS
RENEWAL SUPPLEMENT
Applicant Name:
Risk Management Contact:
Risk Management’s Phone:
Risk Management’s Email:
ACCOUNT INFORMATION
Years this entity in business:
Years experience of this owner:
Is the Applicant compliant with the Zackery Lystedt Law? (Only applicable in Washington)
Yes
Are there procedures in place to verify that individuals and parent carry their own health insurance?
Yes
Yes
1. A copy of the current policy; and
2. 4 years of currently valued loss runs
CONCUSSION - ATHLETICS
1.
Does the Applicant have a written concussion awareness and management program in place, and,
where applicable, is it compliant with current state legislation?
Yes
If yes, does this include:
a.
Understanding a concussion and the potential consequences of this injury?
Yes
b.
Recognizing the signs and symptoms of a concussion or other closed head injury and how to
respond?
Yes
c.
Learning about steps for returning to activity after a concussion?
Yes
d.
Focusing on prevention and preparedness to help keep participants safe?
Yes
*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
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
b.
Does the insured require the participants and / or parents / guardians of minors to sign and
acknowledgement that they have received and reviewed?
Yes
4.
If a concussion is suspected, does the Applicant require the participant to leave the game or
practice immediately?
Yes
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
6.
Does the insured utilize base line testing?
Yes
7.
Does the Applicant currently utilize any concussion impact monitoring technology?
Yes
If yes:
a.
Describe:
A Participant Accident policy is required in order to provide participant liability coverage. Does the
Applicant want a Participant Accident policy quote provided?
**If yes, and the Applicant currently carries A Participant Accident policy, please include:
**If yes, but the Applicant does not currently carry A Participant Accident policy, forward a signed and dated no known
or reported loss letter or a letter listing all incidents and payments for the past 4 years.
Amateur Sports Renewal Supplemental
Leagues / Camps / Clinics
Page 1 of 8
© 2018 Philadelphia Consolidated Holding Corp.
05/2018
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b
Advise the name of the manufacturer:
c.
Advise who monitors the data:
Coaches
Employees
Volunteers
3
rd
Party
ITEMIZED RECEIPTS
Participant Memberships:
$
Alcoholic Beverages:
$
Food and Non-Alcoholic Beverages:
$
Spectator Fees:
$
Other: (Please describe below)
$
ABUSE OR MOLESTATION
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)?
Comments:
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:
Amateur Sports Renewal Supplemental
Leagues / Camps / Clinics
Page 2 of 8
© 2018 Philadelphia Consolidated Holding Corp.
05/2018
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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 Renewal Supplemental
Leagues / Camps / Clinics
Page 3 of 8
© 2018 Philadelphia Consolidated Holding Corp.
05/2018
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LEAGUE EXPOSURE INFORMATION
Sport
Age Group
Number of Participants
Season Dates
12 & Under
Begins:
13 - 16
17 - 18
Ends:
19 & Older
Sport
Age Group
Number of Participants
Season Dates
12 & Under
Begins:
13 - 16
17 - 18
Ends:
19 & Older
Sport
Age Group
Number of Participants
Season Dates
12 & Under
Begins:
13 - 16
17 - 18
Ends:
19 & Older
Sport
Age Group
Number of Participants
Season Dates
12 & Under
Begins:
13 - 16
17 - 18
Ends:
19 & Older
Sport
Age Group
Number of Participants
Season Dates
12 & Under
Begins:
13 - 16
17 - 18
Ends:
19 & Older
Sport
Age Group
Number of Participants
Season Dates
12 & Under
Begins:
13 - 16
17 - 18
Ends:
19 & Older
Sport
Age Group
Number of Participants
Season Dates
12 & Under
Begins:
13 - 16
17 - 18
Ends:
19 & Older
Sport
Age Group
Number of Participants
Season Dates
12 & Under
Begins:
13 - 16
17 - 18
Ends:
19 & Older
Sport
Age Group
Number of Participants
Season Dates
12 & Under
Begins:
13 - 16
17 - 18
Ends:
19 & Older
Other:
Other:
Other:
Other:
Other:
Other:
Other:
Other:
Other:
Amateur Sports Renewal Supplemental
Leagues / Camps / Clinics
Page 4 of 8
© 2018 Philadelphia Consolidated Holding Corp.
05/2018
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CAMP / CLINIC / TOURNAMENT EXPOSURE INFORMATION
Sport
Age Group
Number of
Participants
Per Day
(P)
Number
of Days *
(D)
Total Number of
Camper Days
(P) x (D)
Camp / Clinic or
Tournament Dates
Camp / Clinic
or Tournament
12 & Under
Begins:
Camp / Clinic
13 - 16
Ends:
Tournament
17 - 18
Day or Overnight?
19 & Older
Day
Overnight
Sport
Age Group
Number of
Participants
Per Day
(P)
Number
of Days *
(D)
Total Number of
Camper Days
(P) x (D)
Camp / Clinic or
Tournament Dates
Camp / Clinic
or Tournament
12 & Under
Begins:
Camp / Clinic
13 - 16
Ends:
Tournament
17 - 18
Day or Overnight?
19 & Older
Day
Overnight
Sport
Age Group
Number of
Participants
Per Day
(P)
Number
of Days *
(D)
Total Number of
Camper Days
(P) x (D)
Camp / Clinic or
Tournament Dates
Camp / Clinic
or Tournament
12 & Under
Begins:
Camp / Clinic
13 - 16
Ends:
Tournament
17 - 18
Day or Overnight?
19 & Older
Day
Overnight
Sport
Age Group
Number of
Participants
Per Day
(P)
Number
of Days *
(D)
Total Number of
Camper Days
(P) x (D)
Camp / Clinic or
Tournament Dates
Camp / Clinic
or Tournament
12 & Under
Begins:
Camp / Clinic
13 - 16
Ends:
Tournament
17 - 18
Day or Overnight?
19 & Older
Day
Overnight
Sport
Age Group
Number of
Participants
Per Day
(P)
Number
of Days *
(D)
Total Number of
Camper Days
(P) x (D)
Camp / Clinic or
Tournament Dates
Camp / Clinic
or Tournament
12 & Under
Begins:
Camp / Clinic
13 - 16
Ends:
Tournament
17 - 18
Day or Overnight?
19 & Older
Day
Overnight
Sport
Age Group
Number of
Participants
Per Day
(P)
Number
of Days *
(D)
Total Number of
Camper Days
(P) x (D)
Camp / Clinic or
Tournament Dates
Camp / Clinic
or Tournament
12 & Under
Begins:
Camp / Clinic
13 - 16
Ends:
Tournament
17 - 18
Day or Overnight?
19 & Older
Day
Overnight
Sport
Age Group
Number of
Participants
Per Day
(P)
Number
of Days *
(D)
Total Number of
Camper Days
(P) x (D)
Camp / Clinic or
Tournament Dates
Camp / Clinic
or Tournament
12 & Under
Begins:
Camp / Clinic
13 - 16
Ends:
Tournament
17 - 18
Day or Overnight?
19 & Older
Day
Overnight
Other:
Other:
Other:
Other:
Other:
Other:
Other:
Amateur Sports Renewal Supplemental
Leagues / Camps / Clinics
Page 5 of 8
© 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 COM
PLETED 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 Renewal Supplemental
Leagues / Camps / Clinics
Page 6 of 8
© 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)
Page 1 of 2
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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 KNOWING
LY 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 PRINT
/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
____________________________________________________
SIGNATURE DATE
SECTION TO BE COMPL
ETED 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 LEAGUESCAMPSCLINICS RENEWAL SUPPLEMENT (Philadelphia Insurance Companies)

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Completed 29 July 2020

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