Fillable Application - Craft Brewery And Distillery Renewal36-16355

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Application - Craft Brewery And Distillery Renewal36-16355

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CRAFT BREWERY & DISTILLERY RENEWAL APPLICATION
GENERAL INFORMATION
Legal Business Name:
Website Address:
Association Memberships Held:
Risk Management Contact:
Risk Manager Phone:
Risk Manager Email:
Number of Locations: (complete a separate application for each location)
SECTION I - PRODUCTION & REVENUE INFORMATION
Barrels produced prior year:
Barrels projected coming year:
Revenues prior year: $
Projected revenues coming year: $
Size of brewing/ distilling system:
Manufacturing Revenue Per Location For the Coming 12 Months
Beer – Kegs
$
Beer – Bottles
$
Beer – Cans
$
Liquor/ Spirits
$
“To Go / Carry Out” Beer / Liquor (Growlers, Kegs, 6 Packs, etc.)
$
On-Site Tap / Testing Room Revenue Per Location For the Coming 12 Months
Beer – Draft
$
Beer – Bottles
$
Beer – Cans
$
Liquor/ Spirits – Insured’s Brand(s)
$
Wine/ Other Branded Beer or Liquor/ Spirits (please describe):
$
Food / Non-Alcoholic Beverages
$
Merchandise / Gift Shop
$
1.
Does the Applicant manufacture and/ or package other beverages (i.e. wine, soda, kombucha, etc.)?
Yes
No
If yes, please explain:
2.
What is the Applicant’s current distribution area?
3.
Does the Applicant export any product?
Yes
No
If yes, what percentage of sales: %
To what countries:
Craft Brewery & Distillery
Renewal Application
Page 1 of 4
© 2019 Philadelphia Consolidated Holding Corp.
07/2019
Clear Application
Print Application
SECTION II - POLICIES & PROCEDURES
1.
Does the Applicant have a formal Product Recall Plan in place?
Yes
No
2.
Does the Applicant have a formal Quality Assurance program?
Yes
No
3.
Are tours of the brewing/ distilling production areas provided?
Yes
No
a.
Is there always an employee tour guide?
Yes
No
b.
Are samples provided and ID’s checked for samples?
Yes
No
SECTION III - BREWING/ DISTILLING AND REFRIGERATION EQUIPMENT
1.
Are generators used for power back-up in the event of a power interruption?
Yes
No
If yes, how long will the generators sustain operations?
2.
Are there solar panels in use by the Applicant either attached or on premises?
Yes
No
If yes, is this for Emergency Back-Up Only and is the equipment equal to or less than 500kw in
capacity?
Yes
No
SECTION IV - PROPERTY INFORMATION
1.
Are operations conducted from a residential location?
Yes
No
2.
Is aging / storage in a separate building from the still house?
Yes
No
3.
What type of still is used?
Open System
Closed System
4.
What is the heating source of the still?
Electric
Gas
Steam
Other:
5.
Explosion proof electrical connections?
Yes
No
If yes:
Distance from the still/ brewing equipment, condenser, containers, etc.:
feet
Distance from any Open Transfer Area:
feet
Distance from any Bottling Area:
feet
6.
Pressure relief?
Yes
No
7.
Pressure monitoring alarms?
Yes
No
8.
High temperature limit alarm?
Yes
No
Craft Brewery & Distillery
Renewal Application
Page 2 of 4
© 2019 Philadelphia Consolidated Holding Corp.
07/2019
Clear Application
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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 winterizati
on 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 (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
m
onitoring, heat trace, full insulation on piping or roof):
6.
General Comments:
Craft Brewery & Distillery
Renewal Application
Page 3 of 4
© 2019 Philadelphia Consolidated Holding Corp.
07/2019
Print Application
Clear 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
SECTION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(I
F THIS IS A FLORIDA RISK, PRODUCER MEANS FLORIDA LICENSED AGENT)
PRODUCER LICENSE NUMBER
(I
F THIS A FLORIDA RISK, PRODUCER MEANS FLORIDA LICENSED AGENT)
ADDRESS (STREET, CITY, STATE, ZIP)
Craft Brewery & Distillery
Renewal Application
Page 4 of 4
© 2019 Philadelphia Consolidated Holding Corp.
07/2019
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Completed 2 July 2020

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