Fillable Application - Camp Operators36-10468

Fill Online, Printable, Fillable, Blank Application - Camp Operators36-10468 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 - Camp Operators36-10468

On average this form takes 174 minutes to complete

The Application - Camp Operators36-10468 form is 22 pages long and contains:

  • 0 signatures
  • 67 check-boxes
  • 664 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
 
CAMP OPERATORS APPLICATION
SUBMISSION REQUIREMENTS
• Currently valued insurance company loss runs for the current policy period plus four (4) prior years
• Brochure
• Copy of employment application. The application must include a question asking if the Applicant has ever been
convicted of a crime including sexual abuse
• Copy of consent form for pre-employment background check
• Copy of risk and consent form for campers
• Copy of camp registration form
• Copy of medical permission slip for campers
• Additional supplemental application(s) required (i.e. Go-Karts, Liquor Liability, Fireworks, Water Trampoline, etc.)
• Ropes Course and Zip line inspections
• ACORDS
• If Abuse Coverage is requested a copy of the Applicant’s Sexual Abuse Prevention Policy is required
GENERAL INFORMATION - APPLICANT
Applicant Name:
DBA (if applicable):
Principal Contact:
Mailing Street Address:
Mailing City:
State:
Zip:
Location Street Address:
Location City:
County:
State:
Zip:
Phone Number:
Website: www.
Camp Website:
Risk Management Contact:
Phone:
Email:
Business Form:
Corporation
Partnership
For Profit
Non-Profit
Joint Venture
LLC
Individual
Other:
FEIN:
Effective Date:
Type of Camp:
Day
Resident
Travel
Sports
Weight Loss
(Indicate all that apply)
Co-Ed
Boys
Girls
Adult
Special Needs
Other (describe):
Is the camp accredited by:
ACA
CCI
Other: (specify)
Camp location:
1.
Does the Applicant operate any other businesses 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:
Camp Operators Application
Page 1 of 16
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
Clear Application
Print Application
PRIOR CARRIER INFORMATION
Insurance Carrier
Limits of Liability
Premium
Last Year
$
$
Two Years Ago
$
$
Three Years Ago
$
$
SECTION I – GENERAL INFORMATION
1.
Opening day of camp:
Last day of camp:
Number of sessions:
2.
More than one location?
Yes
No
If yes, attach list of locations and camp function at each.
3.
Total number of camper days.
Day Camps
Resident Camps
Number of campers per day
X
Number of day per week camp is open
X
Number of weeks per year camp is open
=
TOTAL CAMPER DAYS
** If more than one application please provide additional sheet and list each separately**
4.
Age range of campers:
5.
If a resident camp, what is the average length of stay?
6.
Are the camp directors accredited?
Yes
No
.
If yes, by whom:
7.
Does the camp use volunteers?
Yes
No
If yes, at what capacity:
8.
Are there any certified medical personnel (doctor, nurse or other) on the premises during camp?
Yes
No
Number of nurses:
Number of doctors:
If yes, do all certified medical personnel have their own professional liability insurance with a
minimum Limit of Liability of $500,000?
Yes
No
If no, please explain medical procedures:
9.
Does the camp obtain medical permission slips?
Yes
No
10.
Does the camp get written details on all prescription medication being used by its campers?
Yes
No
11.
Nearest medical facility: miles
12.
Name of insurance carrier for the camp’s Participant Accident and/ or Sickness policy:
Policy Number:
Effective Date:
Limit per Camper: $
13.
Does the Applicant require a risk/ consent form to be signed by each camper and their parent(s)
and/or guardian(s)? If yes, please attach a copy.
Yes
No
14.
Does the Applicant accept special needs campers? (If yes, please complete Section VII)
Yes
No
15.
Does the Applicant require a Certificate of Insurance naming the organization as an Additional
Insured from all subcontractors?
Yes
No
16.
When was the last date of inspection by the Board of Health:
17.
Describe cooking facilities (what type of equipment is used to cook):
18.
Is there an automatic fire protection system over all cooking surfaces?
Yes
No
If no, please explain:
19.
Location of nearest fire department: miles
20.
Are there fire hydrants located on the Camp’s premises?
Yes
No
If no, location of the closest fire hydrant: miles
Camp Operators Application
Page 2 of 16
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
Clear Application
Print Application
21.
Do all sleeping quarters have smoke detectors?
Yes
No
If yes, are the smoke detectors:
Battery Operated
Hard Wired
Is there a CO alarm installed?
Yes
No
22.
Do all bunk beds have a continuous guard rail along the wall side of the bunk?
Yes
No
23.
Do any employees live on the camp premises year round?
Yes
No
If yes, describe who and why.
If no, describe security and upkeep measures:
24.
How many buildings are occupied year round?
Who is using the buildings?
25.
Does the Applicant own all buildings associated with the camp and located on the premises?
If no, please explain.
Yes
No
26.
Is the Applicant compliant with the Zackery Lystedt Law? (Only applicable in Washington)
Yes
No
SECTION II – CAMP PERSONNEL
1.
What is the ratio of counselors to campers during all organized activities?
to
2.
What is the ratio of counselors to campers during non-active times?
to
3.
Are counselors always present with campers while on premises?
Yes
No
4.
Regarding counselors from the prior year. What percentage return as personnel for the next year?
%
5.
What is the minimum age of the Applicant’s counselors?
6.
Does the Applicant offer a counselor in training (or other similar type) program?
Yes
No
If yes, what is the minimum age:
7.
Does the Applicant mandate that counselors attend training classes?
Yes
No
8.
What experience is required of the Applicant’s counselors for employment (e.g. training,
certification, or previous experience)? Please describe in detail.
SECTION III - AUTOMOBILE
N/A
1.
Does the camp provide transportation for the campers to and from camp?
Yes
No
2.
Does the camp hire:
Vans
Buses
Other (describe):
What is the size of bus (number of passengers):
3.
Do drivers who transport campers have at least seven years of driving experience?
Yes
No
If no, what are the standards/ requirements?
4.
Does the Applicant have a fleet maintenance supervisor?
Yes
No
Employee Automobile Information:
5.
Are the vehicles ever used by employees for personal use?
Yes
No
6.
Does the Applicant have a formal driving policy in place with MVR standards?
Yes
No
If yes:
a.
Is driving policy communicated in writing to all employees?
Yes
No
b.
Is a signed acknowledgement form kept on file?
Yes
No
c.
Do driving standards include the following:
i.
No major violations including DUI, racing, hit and run, speeding in excess of 20 mph over
posted speed limit, manslaughter?
Yes
No
ii.
No more than 3 moving violations within past 3 years?
Yes
No
iii.
No more than 3 or more accidents (regardless of fault) within past 3 years?
Yes
No
Camp Operators Application
Page 3 of 16
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
Clear Application
Print Application
7.
How often does the Applicant check MVR reports?
8.
Does the Applicant allow any newly hired drivers to operate vehicles without going through a
company-specific documented driver training?
Yes
No
9.
Describe any ongoing training provided to drivers:
10.
Does the Applicant have GPS tracking capability?
Yes
No
11.
Does the Applicant allow employees to drive personal vehicles for company purposes?
Yes
No
If yes:
a.
Are the driving policy and standards for these drivers the same as in questions 6-8 above?
Yes
No
b.
Does the Applicant require these employees to have adequate personal insurance limits?
Yes
No
SECTION IV – RENTAL OF CAMP PREMISES
N/A
1.
Are camp premises rented or leased to an outside entity?
Yes
No
If yes, does the Applicant require a Certificate of Insurance naming the camp as an Additional
Insured?
Yes
No
2.
Is a formal contract/ agreement signed by applicable entities?
Yes
No
If yes, please attach a sample.
Annual gross receipts for the rental of premises to other entities: $
3.
While other entities are on camp premises, is there a representative of the camp on premises at all
times?
Yes
No
If yes, please explain:
4.
Are there any activities that take place during the rental period that do NOT take place during
normal camp operations?
Yes
No
If yes, please describe:
5.
Is liquor sold or furnished during the rental period?
Yes
No
If yes, the Liquor Liability Supplemental Application must accompany this application.
SECTION V – CAMP ACTIVITIES
N/A
1.
Please check all applicable activities associated with the camp.
Adventure Program
Fireworks
Rifle Ranges** #
Alpine Skiing
Flying
Rock Climbing/ Repelling
Archery
Go Karts
Rope Courses/ Climbing Towers
ATV’s
Gymnastics
Rugby
Backpacking
Horse Back Riding
Skateboarding (ramps/ jumps)
Bicycling
Ice Hockey*
Skin or Scuba Diving
Boating
Ice Skating*
Trampolines***
Bubble Soccer/ Knockerball/ Zorbs
Kayaking
Tubing
Caving
Lakes/ Ponds/ Rivers
Water Skiing
Circus Activities
Off Road Bikes (Motorized)
Waterslides over 15’ high #
Contact Football
Paintball
Whitewater Canoeing/ Rafting
Cross Country Skiing
Pools
Ziplines
Drones
Rafting
*Is ice skating/ hockey done on a
rink and/ or
lake/ pond?
**Are NRA standards met with all rifle ranges?
Yes
No
***Land Trampolines excluded under this policy.
Yes
No
If any of the following activities apply, a supplemental application/ questionnaire is required with this submission.
Drones
Go Karts
Water Trampolines - Number:
Fireworks
Paintball
Camp Operators Application
Page 4 of 16
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
Clear Application
Print Application
2.
Does the camp have a written safety plan for all applicable checked activities?
Yes
No
(If yes, please attach a copy for all applicable activities)
3.
Does the camp broker have a contract with others for any of the applicable activities?
Yes
No
If yes, please explain:
4.
Does the Applicant require Certificates of Insurance from all brokered activity providers?
Yes
No
5.
Boating and Water Activities
Please indicate all that apply by listing the number of each unit:
Canoes
Motorboats over 76hp
Rowboats
Jet Skis
Motorboats greater than 21’ in length
Sailboats
Kayaks
Paddle Boats
Tubes
Motorboats less than 76hp
Rafts
Windsurf Boards
a.
Does the Applicant require all campers to wear life jackets during all applicable water
activities?
Yes
No
b.
Is a lifeguard always on duty during water activities?
Yes
No
c.
Does the Applicant require qualified counselors to accompany campers at all times during
water activities?
Yes
No
d.
Are campers permitted to operate motorized boats?
Yes
No
e.
Are water activities restricted to campers only during the specified activity time?
Yes
No
f.
Describe in detail the use of the powered boats:
g.
Are there any whitewater exposures?
Yes
No
Describe exposure:
Counselors affiliated with the whitewater exposure. Please describe their experience and/ or
certification:
6.
Swimming Pools
a.
Total number of pools:
b.
Are all swimming pools and spas compliant with Virginia Graeme Baker Pool and Spa
Safety Act?
Yes
No
If no, provide timetable and action plan.
c.
Maximum depth of each pool:
Are the depth markings clearly visible in and around the pool?
Yes
No
d.
Is each pool fenced in?
Yes
No
Height of fencing around each pool:
e.
Are lifeguards present at all swimming times?
Yes
No
If yes, what is the ratio of swimmers to lifeguards:
to
Are all lifeguards certified?
Yes
No
If yes, how are they certified and by whom?
f.
Are the pool rules posted at each pool area?
Yes
No
g.
Is swimming allowed at night?
Yes
No
If yes, is the pool lighted?
Yes
No
h.
Are any of the pools open to the public?
Yes
No
i.
Is there a diving board?
Yes
No
If yes, what is the height (in feet)?
What is the depth of the water in the diving area?
Is the diving area clearly marked?
Yes
No
Does the diving area extend out at least 16 feet from the end of the diving board?
Yes
No
j.
Is there a water slide?
Yes
No
If yes, please list in feet:
Height:
Length:
Depth of water where slide enters:
If used in a pool, are the slides approved by the manufacturer for pool use?
Yes
No
Camp Operators Application
Page 5 of 16
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
Clear Application
Print Application
How do swimmers enter the water when launching off the slide?
at an angle or
horizontally
Are there spotters at the bottom of each slide?
Yes
No
Who is responsible for the maintenance of the slides:
Are there signs posted regarding proper sliding techniques?
Yes
No
Is head-first sliding allowed?
Yes
No
Please attach rules for use of the water slide.
7.
Lakes, Ponds or Rivers
a.
Total number of:
Lakes:
Ponds:
Rivers:
b.
Maximum depth of each:
Lake:
Pond:
River:
Are the depth markings clearly visible in and around each body of water?
Yes
No
c.
Is each body of water roped off?
Yes
No
d.
Do any of the bodies of water have diving boards?
Yes
No
If yes, height of each diving board:
Depth of water at each diving board entry:
e.
Are lifeguards present at all swimming times?
Yes
No
If yes, what is the ratio of swimmers to lifeguards?
to
Are all lifeguards certified?
Yes
No
If yes, how are they certified and by whom?
f.
Are water safety rules posted at each body of water?
Yes
No
g.
Does the Applicant have water structures like water trampolines, blobs, inflatable platforms,
etc.
Yes
No
If yes, list the type(s) of structure(s)
i. Is there a minimum of 2 lifeguards assigned to each structure at all times?
Yes
No
ii.
Do the lifeguards have 360 degree visibility around the structures?
Yes
No
iii.
Is a maximum 25 pound weight difference between participants on a blob enforced?
Yes
No
iv.
Is only one person at a time allowed to be bounced off the blob?
Yes
No
v.
Are personal floatation devices worn at all times?
Yes
No
vi.
Is there a barrier in place to prevent access to unsupervised structures?
Yes
No
vii.
Is a “no swimming” radius of at least 20 feet around trampolines and blobs enforced at
all times?
Yes
No
viii.
Are all rules posted in a prominent place?
Yes
No
Please attach rules for use of the structures.
h.
Are any of the bodies of water open to the public?
Yes
No
i.
Is a rescue vehicle available?
Yes
No
8.
Gymnastics
a.
Does the camp instruct on floor exercises only?
Yes
No
If no, list all apparatus used:
b.
Details of instructors’ qualifications:
c.
What is the ratio of campers to counselors?
to
d.
Confirm trampolines
ARE FOUR FEET OR LESS IN DIAMETER AND NO MORE THAN TWO FEET ABOVE
FLOOR LEVEL.
Yes
No
9.
Saddle Animals
a.
Number owned:
Number leased:
i.
Is an outside stable used?
Yes
No
ii.
From whom are the horses leased from and what type of contractual agreements are in
place with the owners?
iii.
What capacity are the horses used in the off-season?
Camp Operators Application
Page 6 of 16
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
Clear Application
Print Application
iv.
Where do they stay, how are they cared for, and who handles the activities?
b.
Does the camp offer (check all that apply):
Jumping
Vaulting
Polo
Rodeo Activities
Other (specifiy):
c.
Are all riders required to wear ASTM approved safety helmets?
Yes
No
d.
Does the Applicant provide riding instructors for the mentally or physically handicapped?
Yes
No
If yes, are the counselors NAHRA certified?
Yes
No
e.
Does the camp conduct hayrides?
Yes
No
If yes, does the wagon have sides or is it open?
Sides
Open
Is a counselor in the wagon during rides?
Yes
No
f.
Are the campers taken on trail rides?
Yes
No
g.
What is the ratio of instructor to campers during trail rides: to
h.
Are the animals used during the camp rental periods?
Yes
No
i.
How are the riders matched with horses:
j.
Describe the type of experience required of the instructors:
k.
Does the Applicant have any animals at the camp other than saddle animals?
Yes
No
If yes, describe number and types of each:
Are all animals’ inoculations up to date?
Yes
No
l.
Does the camp teach:
Jumping
Vaulting
Polo
Rodeo Activities
Other (specify):
Are these instructors certified?
Yes
No
If yes, by whom?
HIGH RISK (THE FOLLOWING ARE HIGH RISK EXPOSURES)
10.
Rope Courses/ Climbing Towers
a.
Rope Courses
i.
Describe area and high and low elements: (enclose diagram)
ii.
Has the course been inspected by a certified independent consultant?
Yes
No
iii.
What are the counselor’s qualifications for this course?
iv.
How are they kept restricted when not in use?
v.
What is the ratio of campers to counselors?
to
vi.
What is the height of both high and low ropes courses:
vii.
When was the last inspection? (please provide copy of inspection)
b.
Climbing Towers
i.
Number of climbing towers:
Affixed:
Movable:
If the Applicant has movable, explain:
ii.
Describe activities performed on climbing towers and include a diagram showing
heights, location, settings and equipment used:
Camp Operators Application
Page 7 of 16
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
Clear Application
Print Application
iii.
What are the counselor’s qualifications for this course?
iv.
What is the ratio of campers to counselors?
to
v.
What is the height of each tower/ wall?
vi.
Where are the towers?
Inside or
Outside
vii.
How are they kept restricted when not in use?
viii.
When is the safety training done?
ix.
What type of certification system is used?
x.
What type of equipment is used? Please describe the system.
c.
Zip Lines
i.
Number of Low Courses?
Number of High Courses?
ii.
Are the zip lines inspected annually by a certified independent contractor?
Yes
No
If yes:
a.
By whom?
b.
When was the last inspection done?
Please provide copy of inspection.
iii.
Describe staff training:
iv.
What are heights and lengths of the zip lines:
Height:
Length:
v.
What sort of breaking system does the Applicant’s course use?
vi.
Does the Applicant have padding on its platforms and landing areas?
Yes
No
Camp Operators Application
Page 8 of 16
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
Clear Application
Print Application
SECTION VI – ABUSE OR MOLESTATION
N/A
A COPY OF THE APPLICANT’S SEXUAL ABUSE PREVENTION POLICY IS REQUIRED
1.
Does the Applicant have a written policy specifically defining and prohibiting grooming behaviors?
Yes
No
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.
Does the policy prohibit contact with minor participants outside of the Applicant’s operations
(including social media)?
Yes
No
If yes, please describe:
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.
Independent Contractors
Yes
No
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.
Does the Applicant allow any one-on-one opportunity between employees, volunteers and/ or
independent contractors and the children they serve?
Yes
No
If yes, please describe:
7.
Does the Applicant have any operations where employees, volunteers and/ or independent
contractors will be physically touching another person?
Yes
No
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.
Has the Applicant ever had an incident which results in an allegation of sexual abuse?
Yes
No
If yes, please describe:
Camp Operators Application
Page 9 of 16
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
Clear Application
Print Application
SECTION VII – SPECIAL NEEDS CAMPERS
N/A
1.
What percent of campers have special needs: %
2.
What percent of Applicant’s supervisory personnel have a degree in, or at least 24 weeks
experience in, an area relevant to the special needs being served: %
3.
Are staff/ camper ratios adjusted for special needs campers?
Yes
No
If yes, what is the ratio?
Staff to
Special needs campers
4.
Is the entire staff informed about the limitations/ abilities of the special needs campers
regarding activities, sleeping arrangements, diet, medical requirements, etc.?
Yes
No
5.
Are independent contractors that Applicant uses specially trained to supervisor/instruct special
needs campers?
Yes
No
6.
Does the Applicant’s crisis management plan include contingency plans for these campers?
Yes
No
7.
List the specific medical procedures the Applicant provides:
8.
Do the professionals carry their own malpractice insurance?
Yes
No
If yes, does the Applicant request a Certificate of Insurance as proof?
Yes
No
9.
Does the Applicant have a maintenance program for medical apparatus or equipment that is
provided to campers?
Yes
No
10.
Does the Applicant provide outside services, such as counseling hotlines, seminars or other
activities specific to special needs campers or their families?
Yes
No
If yes, describe:
Camp Operators Application
Page 10 of 16
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
Clear Application
Print Application
SECTION VIII - DIRECTORS & OFFICERS/ EMPLOYMENT PRACTICE LIABILITY
THIS
SECTION
IS
AN
APPLICATION
FOR
A
CLAIMS
MADE
POLICY.
PLEASE READ YOUR POLICY CAREFULLY.
DIRECTORS & OFFICERS LIABILITY INFORMATION
1.
Does the Applicant have a tax-exempt status under the U.S. Internal Revenue Code?
Yes
No
If no, provide an explanation:
2.
FINANCIAL INFORMATION
CURRENT FISCAL YEAR
PREVIOUS FISCAL YEAR
Total Assets
$
$
Net Assets/ Fund Balance
$
$
Annual Revenue
$
$
Net Revenue
$
$
3.
Provide a list of all direct and indirect subsidiaries or any other entity or organization the Applicant controls:
Name / Type of Business
Percent the Applicant
Owns/ Controls
Date Created/
Acquired
For Profit or
Non-Profit
i.e. ABC Foundation / Charitable Foundation
100%
01/01/2000
Non-Profit
%
%
%
Additional entities listed by attachment
4.
Has the Applicant or any person proposed for coverage herein been the subject of, or involved in,
any of the following in the past five (5) years? If yes, please attach details.
Yes
No
Any disciplinary action by any regulatory agency or association?
Yes
No
Any administrative proceeding charging violation of a federal or state law or regulation?
Yes
No
Any other criminal actions?
Yes
No
5.
In the past 24 or next 12 months has the Applicant been, or anticipate being involved in any
merger, acquisitions or consolidation with another entity?
Yes
No
If yes, please attach details.
EMPLOYMENT PRACTICE LIABILITY INFORMATION
1.
Please provide the following employee count information:
U.S. based employees:
Total Full-Time:
Total Part-Time:
Volunteers:
Temporary:
Leased:
Total Non U.S. based employees:
TOTAL SUM OF ABOVE:
2.
Has a reduction in employees or change in of status occurred in the past 12 months or is anticipated
in the next 12 months?
Voluntary:
Involuntary:
Layoffs:
3.
Does the Applicant have an employment handbook that includes an “At Will” statement?
Yes
No
4.
Does the Applicant use an employment application for every potential employee?
Yes
No
5.
Does the Applicant use outside employment counsel for employment advice?
Yes
No
6.
Does the Applicant have a full time, dedicated human resource staff?
Yes
No
7.
Total number of current employees with annual compensation greater than $100,000:
Camp Operators Application
Page 11 of 16
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
Clear Application
Print Application
CURRENT COVERAGE:
COVERAGES
Insurance Company
Limit of Liability
Deductible
Policy
Effective Dates
Premium
D & O
$
$
$
EPLI
$
$
$
Fiduciary
$
$
$
Workplace Violence
$
$
$
Internet Liability
$
$
$
WARRANTY INFORMATION:
1.
With respect to this coverage, has any Underwriter refused, canceled or non-renewed coverage?
(Not Applicable in Missouri)
Yes
No
If yes, please provide details:
2. Has the Applicant given written notice under the provisions of any prior policies providing similar
insurance or claims, or of specific facts or circumstances which might give rise to a claim being
made against any person or entity applying for this insurance?
If yes, complete a Claim Supplemental for each incident.
Yes No
3. No person applying for this coverage is aware of any facts or circumstances which he or she has
reason to suppose might give rise to a future claim that would fall within the scope of any of the
proposed coverages for which the Applicant has applied, except: None or as noted below.
With regard to questions 2. and 3., it is understood and agreed that if any such claim, act, error, omission,
dispute or circumstance exists, then such claim and/or claims arising from such act, error, omission, dispute or
circumstance is excluded from coverage that may be provided under this proposed insurance and, further,
failure to disclose such claim, act, error, omission, dispute or circumstance may result in the proposed
insurance being void, and/or subject to rescission.
Camp Operators Application
Page 12 of 16
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
Clear Application
Print Application
WINTER WEATHER FREEZE-UP PROTECTION
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
Yes No N/A
iv. If yes, is the testing & inspection by qualified sprinkler contractor completed
within past 12 months & includes a formal winterization re
view?
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 (e.g. temperature monitoring,
heat trace, full insulation):
This section must be completed by all risks that have a location in one of the following states: AR, CT, DC, DE,
GA, IL, IN, KY, ME, MD, MA, MI, MO, NH, NY, NJ, NC, OH, PA, RI, SC, TN, TX, VT, VA, WV, WI
temperature?
1. If no, please describe freeze prevention measures (
e.g. temperature
monitor
ing, heat trace, full insulation on piping or roof):
6.
General Comments:
Camp Operators Application
Page 13 of 16
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
Print Application
Clear Application
Clear Application
Print Application
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, 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)
Camp Operators Application
Page 14 of 16
© 2018 Philadelphia Consolidated Holding Corp.
08/2018
Clear Application
Print Application
.
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 Applicant alle
ging 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
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, 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
SEC
TION 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)
Page 2 of 2
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 - Camp Operators36-10468

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