Fillable ARCHERY MANUFACTURERS APPLICATION (Philadelphia Insurance Companies)

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ARCHERY MANUFACTURERS APPLICATION (Philadelphia Insurance Companies)

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ARCHERY MANUFACTURERS APPLICATION
Applicant:
Address:
Website:
Contact Person:
Title:
Telephone Number:
Email:
Risk Manager Contact:
Email:
Telephone Number:
SECTION I – GENERAL INFORMATION
1.
Proposal Effective Date:
2.
Is the Applicant’s current policy on claims made form?
No
If yes, what is the retroactive date:
3.
Limits of Liability: $
4.
Deductible or
Self
Insured Retention per Claim: $
5.
Has any insurer ever canceled, restricted or refused to renew the Applicant’s liability insurance?
No
6.
What does the Applicant anticipate their payroll will be for this year? $
7.
What does the Applicant anticipate their sales will be for this year? $
Period
From / To
Insurance
Company
Total
Premium
Rate Gross Sales
Limit of
Liability
Deductible per
Claim
Current Year
First Prior
Second Prior
Third Prior
Fourth Prior
Please provide us with a copy of the Applicant’s existing Commercial General Liability Policy. If you do not have one,
please check here:
SECTION II – PRODUCT INFORMATION
Applicant’s total sales for the past 4 years: $
M – Manufacturer
W – Wholesaler
R – Retailer
I – Importer
MR – Manufacturers Representative
C – Consumer Direct
O – Other
Type of Products &
Services
Applicant acts as a
# of
Years
# of
Units
Products sold to
M W R I MR W R MR C O
Products and Sales Information – Applicant’s gross receipts from the sale of archery equipment excluding excise tax:
Product
Estimated
Current Year
Sales
# of Units
Total Prior
Year sales
Total Second
Year Sales
Total Third
prior year sales
Total Fourth
Prior Year
Crossbows
Compound
Bows
Bows
Broad heads
Parts
Accessories
Description of Parts or Accessories:
Archery Manufacturers Liability
Page 1 of 8
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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1.
If the Applicant manufactures crossbows, what safety mechanisms are used to prevent
accidental “release/fire”?
2.
List Applicant’s five largest customers:
a.
b.
c.
d.
e.
3.
Has the Applicant discontinued or are they considering discontinuing any product to be covered
by this insurance?
No
If yes, fully describe:
4.
Is the Applicant contemplating any new products?
No
If yes, fully describe:
5.
If the Applicant is a distributor or importer, are they covered by the manufacturer, and do they
secure certificates of insurance or copies of polices showing the
coverage?
No
If yes, provide details on coverage and limits. Attach copies of data. See attached certificate
requirement data sheet.
6.
Can any of the Applicant’s products or services be part of or used on in connection with:
No
• Aircraft/Missile/Aerospace
• Life Support Systems
• Pharmaceuticals/Cosmetics
• Transit
• Transportation
• Watercraft or Offshore
If yes, attach full details.
SECTION III – CORPORATE HISTORY
1.
How many years has the Applicant been in business under the present name or names?
2.
Has the Applicant acquired any companies in the past 10 years?
No
If yes, furnish names of companies and types of products manufactured.
Name of Company
Products Manufactured
3.
Did the acquisition include the assumption of liabilities?
No
If yes, is the loss experience included herein?
No
4.
Has the Applicant ever been declared bankrupt or are you a successor company to a former
bankruptcy?
No
If yes, is Applicant liable for products manufactured by the former company?
No
In a narrative, on a separate sheet, describe how Applicant differs from the former company.
5.
Is the Applicant currently a Debtor in possession or do you anticipate filing for bankruptcy
reorganization with the next year?
No
Archery Manufacturers Liability
Page 2 of 8
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02/2019
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6.
Has the Applicant sold any companies in the last ten years?
No
If yes, furnish names of companies, types of products manufactured and recent sales figures.
Name of Company
Products Manufactured
Sales
$
$
$
7.
Does the sale include liabilities?
No
SECTION IV – PROCESSING
1.
Do others manufacture, assemble or install products under the Applicant’s name?
No
If yes, does the Applicant secure certificates of product liability insurance or are you named as
an additional insured under those policies?
No
2.
Does the Applicant manufacture, assemble, package or install products for others under
another’s name or label?
No
If yes, please describe:
SECTION V – QUALITY CONTROL
1.
Are written quality control and testing procedures followed?
No
2.
How long are quality control records kept?
3.
Do the Applicant’s records indicate when each product was manufactured?
No
4.
Do the Applicant’s records show to whom and the date each product was sold?
No
5.
Do the Applicant’s records show who supplied component parts going into Applicant’s products?
No
6.
If Applicant’s products are manufactured to the specifications of Applicant’s customers, do they
test product upon receipt?
No
SECTION VI – LOSS CONTROL
1.
Does the Applicant have a written products safety program for which specific individuals has
responsibility for implementation?
No
If no, Applicant must agree to implement one.
2.
Are Applicant’s designs subject to independent external review, testing or certifications?
No
If yes, please explain:
3.
Does the Applicant’s legal counsel or other competent person review all instructions, operating
manuals, advertisements and warranties periodically?
No
If no, they must be.
4.
Does the Applicant have a written products recall procedure?
No
If no, Applicant must agree to begin the implementation of one.
If yes, explain fully:
5.
Since the inception of the Applicant’s company, have they issued any notification of, or they
aware of any defect in any products they sell or intend to sell?
No
If yes, explain on a separate sheet.
6.
Has the Applicant ever been requested or advised to recall any products?
No
If yes, explain on a separate sheet.
7.
Has the Applicant ever recalled any products voluntarily?
If yes, what is the Applicant’s estimate of the recovery obtained?
Yes No
Archery Manufacturers Liability
Page 3 of 8
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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8. Does the Applicant offer personal training or instruction in the use of any products? Yes No
If yes, please explain:
SECTION VII - PROPERTY
SECTION VIII - CLAIMS
If Applicant cannot provide insurance company hard copy loss runs for the past 5 years, complete the following:
Policy Year
# of Claims
Total Paid Including Expenses
Total Reserved
Current Year
$
$
First Prior
$
$
Second Prior
$
$
Third Prior
$
$
Fourth Prior
$
$
1.
Has there ever been a claim against the Applicant for $500,000 or more?
No
2.
Is the Applicant aware of any other facts, incidents or circumstances which may result in claims
being made against them?
No
If yes, advise specifics on a separate sheet.
3.
Have there been any municipal class action suits?
No
4.
Have there been any past claims or suits based on distribution or products?
No
1. Please review building security measures listed below:
Fire Alarm: Central Local None Other:
Burglar Alarm: Central Local None Other:
Yes No Is the alarm UL listed or approved?
Smoke Detectors: Battery Hardwired
Doors are: Mental Glass Frame
2. Do windows and glass doors have metal bars? Yes No
3. Describe other protection: (safe, dead bolt locks, metal bars, crash barriers in front of building,
fire extinguishers, etc.)
4. Yes No Does the building have other occupancies?
If yes, describe:
5. Is the building 100% sprinklered? Yes No
6. What is the distance to the nearest fire hydrant:
7. Is there a range on premises for the purpose of testing finished products? Yes No
8. How are finished products stored?
9. How are potential hazards materials stored?
Archery Manufacturers Liability
Page 4 of 8
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02/2019
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SECTION IX – CLAIMS HANDLING AND ACCIDENT PROCEDURES
1.
Does the Applicant have a written procedure for obtaining information involving complaints,
accidents and injuries involving Applicant’s products?
No
2.
Has the Applicant made their distributors aware of your desire for obtaining information
regarding accidents or injuries?
No
3.
Does the Applicant’s procedure provide for examining and preserving any allegedly defective
product?
No
4.
Are the results of such examination recorded?
No
SECTION X – CLAIM DETAILS
Please complete a claim detail report for each claim the Applicant has received in the past five years. Please
put each claim on a separate sheet. You may copy this form is necessary.
1.
Name of Claimant:
2.
Date & location of claim (incident):
3.
When and how did the Applicant learn of the claim:
4.
Has a lawsuit been filed and if so when?
Yes
No
5.
Describe how the accident occurred:
6.
Describe the nature of the injuries:
7.
Describe the nature of the claim being made: i.e., design, defect, failure to warn (inadequate
instructions), manufacturing or material defect, or any other:
8.
If the claim has been settled, what was the amount? $
9.
If the claim has not been settled, has the Applicant’s insurance company indicated to Applicant
how much it expects to pay?
No
If yes, how much? $
10
State the make and model of Applicant’s product involved?
11.
Please give the Applicant’s personal comments about this claim:
Archery Manufacturers Liability
Page 5 of 8
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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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 COMPLETED 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)
Archery Manufacturers Liability
Page 6 of 8
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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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 t
he Applicant 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
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 COMPLETED 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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