Fillable Application - Boat Dealers New Business Supplemental36-8609

Fill Online, Printable, Fillable, Blank Application - Boat Dealers New Business Supplemental36-8609 Form

Use Fill to complete blank online PHILADELPHIA INSURANCE COMPANIES pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Application - Boat Dealers New Business Supplemental36-8609

On average this form takes 61 minutes to complete

The Application - Boat Dealers New Business Supplemental36-8609 form is 6 pages long and contains:

  • 0 signatures
  • 12 check-boxes
  • 237 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Philadelphia Insurance Companies forms online.

BROWSE PHILADELPHIA INSURANCE COMPANIES FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
BOAT DEALER SUPPLEMENTAL APPLICATION
(Include with ACORD application)
Applicant Name:
Date:
Billing contact name:
FEIN:
SIC code:
Risk Management Contact:
Risk Management’s Phone:
Risk Management Email:
COVERAGES REQUESTED
Marina Operators Legal Liability coverage limit requested
$500,000
$1,000,000
$2,000,000
$3,000,000
$4,000,000
Marina Operators Legal Liability Deductible
$1,000
$2,500
$5,000
Protection & Indemnity limit requested
$100,000
$250,000
$500,000
$1,000,000
Equipment / Tools (use ACORD if additional coverages are needed)
Limit: $
Description:
*Note: Insured tool limit of $25,000 provided on Elite Property Enhancement
All Property excluding Boat Stock/ Inventory (Make sure it is clearly indicated on the ACORD form)
Stock / Inventory – Fill out Section IV of this application.
General Liability – Make sure description and exposure (receipts/ payroll, etc.) are clearly indicated on ACORD.
SECTION I – GENERAL INFORMATION
1.
Gross Annual Receipts
Annual Payroll
Boat Sales:
$
Repair (Labor) $
Parts & Accessories:
$
ATV Sales:
$
Snowmobile Sales:
$
Jet-Ski Sales:
$
Fueling:
$
Snack Bar/ Restaurant:
$
Rental:
$
Cabin/ Dwelling Rentals:
$
Storage/ Moorage Sales:
$
Miscellaneous Receipts:
$
Description:
2.
State period of seasonal operation, If any:
to
3.
During closed period, what steps are taken to protect premises: (Describe):
4.
Body of water:
Boart Dealers New Business Supplemental
Page 1 of 6
© 2020 Philadelphia Consolidated Holding Corp.
03/2020
Clear Application
Print Application
SECTION II – PROTECTION AND INDEMNITY
1.
For owned watercraft, indicate number, length and horsepower:
2.
Please fully describe owned watercraft operation if the Applicant is requesting P & I coverage
for this exposure:
3.
Please fully describe rental operation if the Applicant is requesting P & I coverage for this
exposure:
SECTION III – GENERAL LIABILITY
Explain all “Yes” responses:
1.
Does the Applicant install service or demonstrate products?
Yes
No
2.
Foreign products sold, distributed, used as a component?
Yes
No
3.
Research and development conducted or new products planned?
Yes
No
4.
Guaranties, warranties, hold harmless agreements?
Yes
No
5.
Products recalled, discontinued, changed?
Yes
No
6.
Products of others sold or repackaged under Applicant’s label?
Yes
No
7.
Products under label of others?
Yes
No
8.
Does any named insured sell to other named insured?
Yes
No
9.
Products manufactured?
Yes
No
Explanations:
Please attach literature, brochures, labels, warnings etc.
General Information: ( Explain all “Yes” responses below):
1.
Any exposure to radioactive/ nuclear material?
Yes
No
2.
Do operations involve storing, treating, discharging, applying, disposing, or transporting of
hazardous material?
Yes
No
3.
Any operations sold, acquired, or discontinued in last five (5) years?
Yes
No
4.
Any structural alterations contemplated?
Yes
No
5.
Any demolition exposure contemplated?
Yes
No
6.
Are there any pools on the premises?
Yes
No
a.
Are all swimming pools and spas compliant with Virginia Graeme Baker Pool and Spa
Safety Act?
Yes
No
b.
If no, provide time table and action plan:
Boart Dealers New Business Supplemental
Page 2 of 6
© 2020 Philadelphia Consolidated Holding Corp.
03/2020
Clear Application
Print Application
Explanation:
7.
Is there a repair facility on premises?
Yes
No
If yes:
Number of repairs in the last twelve (12) months:
Maximum values in repair facility at any one time: $
Maximum value of any product repaired: $
Average value of any repair: $
Is the work inspected by foreman/ owner before delivering to customer?
Yes
No
Are customers kept out of shop area?
Yes
No
Are mechanics certified by the manufacturer?
Yes
No
By whom:
What type of repair work is done:
8.
Is there a fueling operation on premises?
Yes
No
If yes:
Who fuels the watercraft:
Gas and /or diesel:
Condition of hoses and tanks:
Proximity to water:
9.
Dealer Operation
Is the Applicant or his authorized employee in command of the boat at all times?
Yes
No
What types of boats are sold: (runabouts, pontoons, houseboats, etc.)
10.
Is there a towing service available?
Yes
No
Total receipts generated by towing operation: $
What types of vessels are used:
11.
Please describe general condition of boat dealer operation.
Lighting:
Safety Signs:
Smoke Detectors:
Burglar and Fire Alarm:
13. Please give any other special area of concern or additional GL exposures:
(Boat brokers, Bottom cleaning divers, Trailer parks and/ or excursion boats)
SECTION IV – BOAT DEALERS
1.
Total inventory value: (no item over $300,000 to be included) $
How many items between
$5,000 - $10,000:
$10,000 - $25,000:
$25,000 - $50,000:
$50,000 - $100,000:
$100,000 - $300,000:
Total inventory value (over $300,000 individually): $
Boart Dealers New Business Supplemental
Page 3 of 6
© 2020 Philadelphia Consolidated Holding Corp.
03/2020
Clear Application
Print Application
How many items between
$300,000 - $500,000:
$500,000 - $1,000,000:
$1,000,000 +:
YEAR
MAKE/ MODEL
VALUE
SERIAL NUMBER
$
$
$
$
$
$
$
$
$
2.
Inventory: Physical damage coverage on boats, ATVs, snowmobiles, jet skis, motors, trailers, and
supplies held for sale (i.e. inventory) (Inventory dates should be at least six (6) months apart)
Last inventory date:
Value: $
Prior inventory date:
Value: $
Location 1
Location 2
Location 3
Location 4
Values in building:
$
$
$
$
Values in open area:
$
$
$
$
Values in water:
$
$
$
$
Sales New % Used %
Does the Applicant allow unaccompanied test rides by customers? Yes No
Limit for property at any other location (boat shows and exhibits): $
Limit for property in transit at your risk: $
Is an assembly of the products required? Describe: Yes No
3.
Did the manufacturer train / certify your assemblers? Describe:
Yes
No
4.
Does the manufacturer require a minimum age for use/ sale of their products?
Yes
No
Describe precautions taken to ensure the manufacturer’s rules are strictly followed:
5.
Is the Applicant’s dealership listed/ covered as a vendor under the manufacturer’s policy?
(Attach certificate)
Yes
No
6.
Is there a hold harmless agreement in place between the manufacturers and the
Applicant’s dealership?
Yes
No
7.
Does the Applicant sell any used 3-wheeled ATV’S?
Yes
No
Boart Dealers New Business Supplemental
Page 4 of 6
© 2020 Philadelphia Consolidated Holding Corp.
03/2020
Clear Application
Print Application
8.
Storage
Location 1
Location 2
Location 3
Location 4
Maximum # of products stored
in building at any one time:
Maximum # of products stored
in the open at any one time:
Estimated total value in
storage:
$
$
$
$
9.
Any wet storage?
Yes
No
10.
Any multi-tiered storage?
Yes
No
If yes, is forklift operation restricted to specially trained employees?
Yes
No
SECTION V – LIMITED POLLUTION
1.
Is the Applicant interested in Limited Pollution coverage?
Yes
No
2.
Does the Applicant have a current Environmental policy?
Yes
No
3.
Does the Applicant have any storage tank systems?
Yes
No
4.
Is the Applicant seeking coverage for remediation and/or clean-up?
Yes
No
If the Applicant answered “yes” to question 2, 3, or 4 above would you like a separate
Environmental quote?
Yes
No
SECTION VI - LOSS RECORD
Please attach a detailed description of all claims incurred greater than $10,000 during the past five years to property or
from operations covered by this form of policy, including date, cause, amount paid or estimated amount, if claim not
settled, and actions taken by the insured to prevent a similar claim in the future. If none, state “none”.
Currently valued insurance company loss runs for the current policy period plus three prior years
Please attach all of the insured’s agreements with customers.
Boart Dealers New Business Supplemental
Page 5 of 6
© 2020 Philadelphia Consolidated Holding Corp.
03/2020
Clear Application
Print Application
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, 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 VERMONT: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY
OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW.
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.
NA
ME (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)
Boart Dealers New Business Supplemental
Page 6 of 6
© 2020 Philadelphia Consolidated Holding Corp.
03/2020
Clear Application
Print Application
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Application - Boat Dealers New Business Supplemental36-8609

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 2 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document