Fillable AXE / HATCHET THROWING APPLICATION (Philadelphia Insurance Companies)

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AXE / HATCHET THROWING APPLICATION (Philadelphia Insurance Companies)

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AXE / HATCHET THROWING APPLICATION
SUBMISSION REQUIREMENTS
• All brochures describing any and all services; or website address.
• The liability waiver / hold harmless agreement you require your guests to sign, if applicable.
• Currently valued insurance company loss runs for the current policy period plus 3 prior years
if unavailable, provide a no loss letter signed by the insured.
•
ACORD forms for other lines requested (Property, Inland Marine, Crime, etc.)
GENERAL INFORMATION
Applicant:
Principal Contact:
Mailing Street Address:
Mailing City: State: Zip:
Location Street Address:
Location City: County: State: Zip:
Phone Number:
Fax Number:
Website: www.
Business Type:
Corporation
Partnership
Individual
Other:
Effective Date:
Risk Management Contact:
Risk Management’s Phone:
Risk Management Email:
Limit of Liability requested:
$ 300,000 Occurrence
$ 500,000 Occurrence
$1,000,000 Occurrence
1.
Does the Applicant operate any other business from this location?
Yes
No
(List information below for each business, use a separate sheet to list information if necessary)
If yes, type of entity: Corporation
Partnership
Individual
LLC
Other:
Description of business:
2.
Does the Applicant have separate insurance for this business?
Yes
No
SECTION I - PRIOR CARRIER INFORMATION
Insurance Carrier Limits of Liability Premium
Last Year
Two Years Ago
Three Years Ago
SECTION II - ADDITIONAL INSUREDS
if necessary use another sheet of paper
Name Complete Address Interest
SECTION III - PRODUCING INSURANCE AGENT
FAX:
AGENCY:
CONTACT:
ADDRESS:
TELEPHONE:
E-MAIL:
THIS IS AN APPLICATION FOR INSURANCE. THIS IS NOT A BINDER OF INSURANCE.
3. Is the Applicant a member of WATL? Yes No
Axe Hatchet Throwing Application
Page 1 of 5
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
Print Application
Clear Application
SECTION IV - PROPERTY SECTION
N/A
1.
Please review building security measures listed below:
Fire Alarm:
Yes
No
Central
Local
Burglar Alarm:
Yes
No
Is the alarm UL listed or approved?
Yes
No
Central
Local
Smoke Detectors:
Yes
No
Battery
Hardwired
2.
Doors are:
Metal
Glass
Frame
3.
Do windows and glass doors have metal bars?
Yes
No
4.
Describe other protection: (safe, dead bolt locks, metal bars, crash barriers in front of
building, fire extinguishers, etc.)
5. If the Applicant’s building is more than ten (10) years old, what year was the last time
wiring, plumbing and heating / AC were updated and / or serviced?
6.
Does the building have other occupancies?
Yes
No
If yes, describe:
7.
Are there any additional locations to be covered?
Yes
No
If yes, please provide complete address and describe:
8. Is the building within city limits? Yes No
9. Is the building 100% sprinklered? Yes No
10.
What is the distance to the nearest fire hydrant?
11. Other activities conducted on the premises:
SECTION V - RETAIL OPERATIONS
N/A
1.
$
$
$
$
Location Information
Estimated gross revenue for the next twe
lve (12) months:
Revenues from axe throwing ranges:
Revenue from sale of alcohol:
Revenues from sale of sporting goods:
Other revenue, describe:
$
Axe Hatchet Throwing Application
Page 2 of 5
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
Clear Application
Print Application
SECTION VI - RANGE OPERATIONS
N/A
1.
Is the range in compliance with any recognized standards? (i.e. NATF,
WATL
)
Yes
No
2.
Does the range have any age restrictions?
Yes
No
If yes, please describe:
3.
Indoor Range?
Yes
No
Number of Lanes:
Outdoor Range
Yes
No
Number of Lanes / Stations:
Maximum Distance Thrown:
4. Axe Throwing
Yes
No
a.
Is a supervisor on duty at all times?
Yes
No
b.
Are supervisors first aid certified?
Yes
No
c.
Are waivers mandatory? (Please provide a copy)
Yes
No
5. Number of range supervisors:
Max ratio of supervisors to lanes:
6. Type of certification of range supervisors:
7. Does the Applicant have written rules prominently displayed? Yes No
8. Does the Applicant provide lessons? Yes No
If yes, provide qualifications of instructors:
9. Number of annual participants:
SECTION VII - LIQUOR
1. Does the Applicant possess Liquor Liability insurance? Yes No
If yes, please provide licensee name/number/state:
2. Has the Applicant or any owner ever had a liquor license revoked or suspended? Yes No
If yes, please explain:
3. Has the Applicant had any violations or claims in the past 5 years? Yes No
If yes, please explain:
4. Are patrons or guest bartenders allowed to serve alcohol? Yes No
If yes, please explain:
5. Does the Applicant sell whole bottles of hard liquor to tables? Yes No
6. Does the Applicant have written guidelines for checking ID? Yes No
7. Are alcohol servers trained in documented, responsible alcohol serving techniques (i.e.
TIPS, TAM, RAMP, BEST, etc.)?
Yes No
Axe Hatchet Throwing Application
Page 3 of 5
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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8.
Is any training provided for servers in handling of minors or intoxicated customers?
Yes
No
If yes, please explain:
9.
Does the Applicant allow “BYOB” on premises?
Yes
No
10.
Average cost of beer/wine/mixed drinks:
Beer:
$
Wine Bottle:
$
Wine Glass:
$
Mixed Drinks:
$
11.
Average size of glasses/cups:
oz.
12.
Does the Applicant run or plan to run the following alcohol promotions:
a.
Reduced drink prices for more than 2 hours?
Yes
No
b.
Any prices reduced to $1.00 or less?
Yes
No
c.
Multiple drink incentives (i.e. 2 for 1, every 3
rd
drink is free, etc.)?
Yes
No
d.
Complimentary drinks or “all you can drink” specials (other than banquets, some
rentals)?
Yes
No
13.
Does the Applicant offer flaming or ignited drinks?
Yes
No
14.
Does the Applicant ever permit employees who serve liquor to consume alcohol on the
job?
Yes
No
15.
Does the Applicant ever permit employees who serve liquor to consume alcohol after
shifts?
Yes
No
16.
Does the Applicant sell packaged goods for off-premises consumption?
Yes
No
17.
Are persons under the legal drinking age allowed on premises after 10 p.m.?
Yes
No
18.
Does the Applicant provide 3
rd
party transportation (i.e. cabs)?
Yes
No
Axe Hatchet Throwing Application
Page 4 of 5
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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
SE
CTION 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)
Axe Hatchet Throwing Application
Page 5 of 5
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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AXE HATCHET THROWING APPLICATION (Philadelphia Insurance Companies)

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Completed 29 July 2020

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