Fillable Application - Bowling Center Supplemental36-11687

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Application - Bowling Center Supplemental36-11687

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BOWLING CENTER SUPPLEMENTAL APPLICATION
SUBMISSION REQUIREMENTS
•
Complete signed / dated Supplemental Application(s)
• Completed ACORD Applications
• Currently valued insurance company loss runs for the current policy period plus three (3) prior years
•
Color photographs (Interior and Exterior of EACH Center)
•
Financials - current and prior year or current Income tax return
ACCOUNT INFORMATION
Applicant Name:
Physical address:
Risk Management Contact:
Cell Phone:
Email:
Annual Gross Revenues:
PAST 12 MONTHS
Bowling (including shoe rental)
$
$
Restaurants / Snack Bar
Food
$
$
Liquor
$
$
Pro Shop
$
$
Arcade
$
$
Bar / Lounge
Food
$
$
Liquor
$
$
Banquet Hall
Food
$
$
Liquor
$
$
Off Site Catering*
$
$
*No off site liquor service permitted
Retail Sales
$
$
Other – please describe:
$
$
TOTAL GROSS REVENUES:
$
$
UNDERWRITING INFORMATION
BOWLING ACTIVITIES:
1.
Total years in business:
At this location:
Hours of operation:
to
2.
Number of lanes:
Does Applicant contract lane refinishing?
Yes
No
3.
Lane construction:
Wood
Synthetic
4.
Lane Finish: (Flammable means the flash point is less than 80 degrees)
Lacquer – Not eligible for the program
Polyurethane – if flammable, need product code:
Urethane – if flammable, need product code:
Water Based
5.
Any pin refinishing done on premises?
Yes
No
If contracted, are certificates of insurance obtained?
Yes
No
What limit of insurance is carried by sub-contractor: $
6.
Are ball racks secured / anchored to the floor?
Yes
No
7.
Does Applicant’s bowling center have automatic scoring equipment?
Yes
No
Bowling Center Supplemental
Page 1 of 8
© 2017 Philadelphia Consolidated Holding Corp.
06/2017
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8.
Are any flammable liquids stored on premises?
Yes
No
If yes, list products and quantities:
Are all flammable liquids stored in UL approved containers?
Yes
No
9.
Percentage of business from:
League activity: %
Open Play: %
10.
Does Applicant sponsor any professional tournaments?
Yes
No
If yes, list events and sponsoring organization:
If yes, are certificates of insurance obtained from sponsoring organization?
Yes
No
11.
Does Applicant have a Pro shop on premises?
Yes
No
Is Applicant’s Pro an:
Employee
Independent Contractor
If an Independent Contractor, is insurance placed elsewhere?
Yes
No
If leased to a third party, please provide the square footage:
(Certificate of Insurance is required.)
12.
How many Automatic External Defibrillators (AED) does the Applicant have at each location?
13.
How many employees at each location are trained to operate an AED?
14.
Was full CPR training included with the AED training?
Yes
No
BUILDING INFORMATION
1.
Year constructed:
2.
Year of updates:
Electric:
Heating:
Plumbing:
Roof:
*NOTE: If building is over 20 years, must have been completely gutted to be eligible.
3.
Roof type (flat, wood bowstring truss, etc.):
If bowstring truss is frame, building is not eligible.
4.
Building Construction:
Block
Metal
Frame
Other:
5.
Building Area: (square feet)
6.
100% value of bowling lanes and bowling equipment: $
Bowling lanes and equipment to be covered:
Replacement Cost
ACV
Bowling Lanes and Equipment Values are included in:
Building Value
Contents Value
7.
Is building 100% sprinklered including pin setting areas? (must be ISO rated)
Yes
No
8. Are all areas of buildings with wet pipe sprinkler systems (hidden or unhidden) maintained at
a minimum temperature of 40° F, and / or provided with proper insulation or heat tracing to
prevent pipe freeze-ups?
Yes
No
9.
Central Station Alarms?
Yes
No
If yes, what type?
Smoke/Heat
Burglar
Fire
Name of alarm monitoring service:
10.
Parking Lot:
Paved
Gravel
Dirt
Lighted
Other:
Security cameras?
Yes
No
11.
If PC 7 and above, need responding fire department:
Miles to station:
12.
Which of the following does the center use to minimize damage from lightning:
Overload Circuit Breakers
In-Line Lightning Resistors
Ground Fault Circuit Interrupters
Surge Protectors
Other:
OPERATIONS
1.
Does Applicant lease its facility for birthday parties or banquets?
Yes
No
Please describe the type of banquets:
2.
Does Applicant provide child care services?
Yes
No
If yes, what is the maximum number of children at any one time:
If yes, what is the ratio of adults to children:
If yes, what is the minimum age of child care staff:
If yes, what is the minimum age of children:
Bowling Center Supplemental
Page 2 of 8
© 2017 Philadelphia Consolidated Holding Corp.
06/2017
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3. Does Applicant’s employment process (for employees and volunteers) include verification of
whether the individual has ever been convicted of any crime, including sex-related or chi
ld
abuse offenses before an offer is made?
Yes No
4. Any other activities or business operations? Yes No
If yes, please describe:
Coin Operated Amusements Annual Receipts: $
How many: Number of attendants:
Equipment is: Owned Leased
Are machines properly grounded? Yes No
Is there an on-site maintenance shop? Yes No
Is there adequate maintenance equipment on-site? Yes No
Bumper Boats Annual Receipts: $
How many: Manufacturer:
Number of operators: Height of observation fence: ft.
Age / Height limit – At least 10 years and 48”? Yes No
Depth of water four (4) feet or less? Yes No
Max. engine HP:
Bumper Cars Annual Receipts: $
How many: Manufacturer:
Min. height requirement: in. How many attendants:
Type of seat belt:
Cars equipped with dash and headrest pads? Yes No
Wheel pads on steering wheels? Yes No
Batting cages – WAIVER AND RELEASE REQUIRED Annual Receipts: $
How many: Manufacturer:
Min. age requirement: Mfg. age / speed recs. Posted:
Clearly marked for right or left handed hitters? Yes No
Are home plates clearly marked? Yes No
Machine velocity checked or calibrated? Yes No
If yes, by whom:
Are records kept: Yes No For how long:
Are pitching machine settings able to be altered by hitters? Yes No
Helmet or other safety equipment required to be used by participants in cages? Yes No
Light or similar indicator when last ball has been pitched? Yes No
Coin Operated rides Annual Receipts: $
How many: Describe:
Go-karts – Waiver and Release Required if over 21 mph Annual Receipts: $
How many: Number of tracks:
Maximum speed: mph Indoor / outdoor:
Max. number on track any one time: Number of attendants:
Gas or electric:
Minimum Age: Minimum Height:
Seat belts required? Yes No
Equipment with governors to control speed? Yes No
Operator cut off system? Yes No
Outdoor tracks fenced? Yes No
Equipped with roll bars and bumper guards? Yes No
Fences meet ASTM F-24 requirements? Yes No
Track rules clearly and prominently posted? Yes No
Inflatables / Bounce and Play Annual Receipts: $
Describe:
Bowling Center Supplemental
Page 3 of 8
© 2017 Philadelphia Consolidated Holding Corp.
06/2017
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Miniature Golf
Annual Receipts: $
Number of courses:
Number of holes:
Waterfall or fountains – with ground fault interrupters?
Yes
No
Driving Ranges
Annual Receipts: $
Number of stalls:
Partitions between stalls?
Yes
No
Paintball – Laser Tag WAIVER AND RELEASE REQUIRED
Annual Receipts: $
Minimum age: Minimum height: Maximum participants per game:
Ratio of judges to participants:
Written instructions, procedures and training provided for participants?
Yes
No
Does equipment meet ASTM standards?
Yes
No
Specify types of air fills used:
Are safety plugs mandatory?
Yes
No
Does Applicant repair or modify equipment sold?
Yes
No
Is there a scheduled maintenance plan for equipment?
Yes
No
If yes, please provide details:
Do manufacturers provide certificates of insurance including you as Additional Insured?
Yes
No
Are participants separated by level of experience?
Yes
No
Are spectators properly protected from the paintball area / field?
Yes
No
Are participants in violation of the safety rules ejected?
Yes
No
List protective gear supplied to participants:
Indicate feet per second used at your location:
How often is equipment inspected:
How often is equipment changed:
Facility enclosed or fenced?
Yes
No
Any barriers or obstacles?
Yes
No
If yes, please describe or provide diagram:
Any hand to hand fighting allowed?
Yes
No
Are customers allowed to bring their own equipment?
Yes
No
If yes, is equipment and velocity checked?
Yes
No
Is eye protection required?
Yes
No
Are employees trained in first aid?
Yes
No
Rock Climbing Wall - Waiver and Release Required if over 5’
Annual Receipts: $
Does rock wall meet all CWIG (Climbing Wall Industry Group) standards and local codes?
Yes
No
What is the height of the wall:
Bouldering (traversing) wall only – 6’ or less?
Yes
No
Are participants allowed to climb on their own?
Yes
No
What is the check in procedure:
What kinds of verbal contacts or warnings given:
When is safety testing done:
What type certification system is used:
What type of equipment is used:
Describe the belay system:
What type of landing surface is used – describe makeup, thickness and extent of fall protection:
Who is responsible for daily maintenance and checks:
Are spotters required?
Yes
No
At what height:
Does Applicant have a portable wall?
Yes
No
If yes, what is frequency of use off premises:
Bowling Center Supplemental
Page 4 of 8
© 2017 Philadelphia Consolidated Holding Corp.
06/2017
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Miscellaneous Activities:
Number of Participants
Annual Receipts
Euro bungee
$
Trampolines
$
Rope ladders
$
Mechanical bull
$
Shuffleboard
$
Volleyball / Basketball
$
Tennis courts
$
Billiard / Pool table
$
Simulators
$
RESTAURANT / SNACK BAR EXPOSURE
1
Please check all that apply:
Snack Bar
Restaurant
Bar
Banquet Hall
Is the restaurant leased to a third party?
Yes
No
If yes, provide the square footage of the restaurant/snack bar:
(certificate of insurance is required)
2.
Are all cooking surfaces protected by a hood and duct system?
Yes
No
Does Applicant have a service contract with a contractor to clean the hood and duct
system?
Yes
No
3.
Is there an automatic extinguishing system?
Yes
No
What type of automatic extinguishing system is in place:
How often is the system serviced and maintained:
Monthly
Quarterly
Semi-Annual
Annual
4.
Does Applicant have a deep fat fryer on premises?
Yes
No
5.
Are portable fire extinguishers provided in the kitchen?
Yes
No
Last service date:
6.
Are food and beverages permitted in the bowling area?
Yes
No
LIQUOR LIABILITY
1.
Liquor license name:
2.
Liquor license number:
Class of license:
3.
Has Applicant’s alcoholic beverage license ever been revoked or suspended?
Yes
No
If yes, explain:
4.
Has Applicant had any occurrences that have arisen out of the sale of any alcoholic
beverages?
Yes
No
5.
Current Liquor Liability insurance carrier:
Limits: $
Premium: $
6.
Has Applicant’s liquor liability insurance been canceled or non-renewed in the last
three (3) years? If yes, explain:
Yes
No
7. Has Applicant ever been fined by alcoholic beverage control or other governmental
regulator?
Yes
No
If yes, explain:
8.
Has Applicant ever filed for bankruptcy?
Yes
No
If yes, explain:
9.
Type of beverages sold:
% Beer
% Wine
% Other:
Bowling Center Supplemental
Page 5 of 8
© 2017 Philadelphia Consolidated Holding Corp.
06/2017
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10.
Are patrons allowed to carry alcoholic beverages onto the premises?
Yes
No
If yes, what type:
11.
Number of servers used:
Professional? (2 years or more bartender experience)
Yes
No
Non-Professional? (no bartender experience)
Yes
No
If yes, please explain:
12.
Are all employees and/or volunteers that serve alcohol certified in a formal alcohol training
course?
Yes
No
If yes, provide name of course:
TIPS
TAM
RAMP
BEST
Other:
13.
At what location are IDs checked and how often:
14.
In what size container are alcoholic beverages served:
Glass/Cup
oz.
Pitcher
oz.
Other:
15.
Is there a limit placed on the quantity of alcoholic beverages purchased at one time?
Yes
No
If yes, please explain:
16.
Does Applicant serve beer or alcohol from “bar carts”?
Yes
No
17.
Is Bar/Restaurant open when bowling lanes are closed?
Yes
No
18.
Does bowling center feature any entertainment?
Yes
No
How often:
Type of entertainment featured:
DJ
Jukebox
Karaoke
Solo Vocalist
Band (1-3 members)
Band (4+members)
Other:
If musical entertainment, what type:
Top 40’s / Pop
Alternative
Classic Rock
Country
Jazz
Rap
Soft Rock
R&B
Other:
Is dancing permitted?
Yes
No
Is there a dance floor?
Yes
No
Is there a minimum or cover charge?
Yes
No
19.
Is the parking area patrolled to prevent intoxicated drivers from leaving the premises?
Yes
No
20.
Is there any type of designated driver program in effect?
Yes
No
21.
Describe security measures in place:
Number of uniformed police officers present at the site of alcohol sales:
Number of undercover police officers present:
Number of private security present:
Other:
22.
Are rules and regulations clearly displayed for patrons viewing?
Yes
No
Explain:
23.
Other promotional activities or events:
24.
Type of clientele:
Area Residents
Area Workers
Tourists
College
Other:
25.
Average age of patrons:
Percentage of clientele: Under 25: %
25-30: %
Over 30: %
26.
Is an Additional Insured needed?
Yes
No
Name:
Address:
Describe Interest:
Bowling Center Supplemental
Page 6 of 8
© 2017 Philadelphia Consolidated Holding Corp.
06/2017
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NON-OWNED / HIRED AUTOMOBILE COVERAGE
1.
Does Applicant have a business auto policy for owned autos?
Yes
No
2.
Do employees or volunteers routinely use their autos for company business?
Yes
No
If yes, explain:
3.
Total number of employees:
Volunteers:
WINTER WEATHER FREEZE-UP PROTECTION
This section must be completed by all risks that have a location in one of the following states: AR, CT, DE,
GA, IL, IN, KY, ME, MD, MA, MI, MO, NH, NY, NJ, NC, OH, PA, RI, SC, TN, TX, VT, VA, WV, WI
1.
Fire Protection and Testing
a.
Is the building provided with an Automatic Fire Sprinkler System (AS)?
Yes
No
N/A
i.
If yes, approximately what percentage (%) of the building is sprinklered?
%
ii.
If yes, what type of sprinkler system is installed?
Wet-Pipe
Dry-Pipe
Both
iii.
If yes, when possible, is the sprinkler piping primarily run within conditioned
areas designed to ensure the temperature remains above the 45°F
minimum temperature requirement of NFPA-13, NFPA-13D, and NFPA-
13R?
Yes
No
N/A
1.
If no, please describe freeze prevention measures (temperature
monitoring, heat trace, full insulation on piping or roof:
iv.
If yes, is the testing & inspection by qualified sprinkler contractor completed
within past 13 months & includes a formal winterization review?
Yes
No
N/A
v.
If yes, are the alarms tied to a 24 hour UL listed monitoring company?
Yes
No
N/A
2.
Emergency Water Response (domestic and AS water lines)
a.
Are water shutoff valves (domestic and AS water lines) marked and readily
accessible?
Yes
No
N/A
b.
Are water shutoff valves exercised (closed and reopened) at least annually?
Yes
No
N/A
c.
Is the staff qualified to respond and shut off the water main during normal
business hours and off hours?
Yes
No
N/A
3.
Automatic Water Shutoff Devices
a.
For domestic water lines, is there a water flow detection, notification and
automatic shutoff?
Yes
No
N/A
4.
Unused/Vacant Spaces
a.
Does Applicant have a formal process to turn off and drain domestic water lines
for these spaces?
Yes
No
N/A
5.
Unheated Areas (attics, crawl spaces, exterior wall joists)
a.
Are all domestic water lines located in areas heated to at least 45°F?
Yes
No
N/A
i.
If no, please describe freeze prevention measures (temperature monitoring,
heat trace, full insulation):
6.
Ice dams (if applicable)
a.
Does the attic insulation meet the R rating recommended by the Department of
Energy's 1 - 8 zones?
(www.energystar.gov/?c=home_sealing.hm_improvement_insulation_table)
Yes
No
N/A
NOTE: Manufacturers have created varying densities to allow for higher R-values in
smaller cavities. Typically R-values are R-11 to R-15 for 2” X 4” construction, up to
R-21 for 2”X6” construction, and R-38 for 12” spaces, such as within the attic.
7.
General Comments:
Bowling Center Supplemental
Page 7 of 8
© 2017 Philadelphia Consolidated Holding Corp.
06/2017
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)
Bowling Center Supplemental
Page 8 of 8
© 2017 Philadelphia Consolidated Holding Corp.
06/2017
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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 again
st the 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
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, 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.
NAM
E (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
____________________________________________________
SIGNATURE DATE
SECT
ION TO BE COMPLETED BY THE P
RODUCER/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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Application - Bowling Center Supplemental36-11687

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Completed 2 July 2020

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