Fillable Application - Craft Brewery And Distillery Supplemental36-8438

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Application - Craft Brewery And Distillery Supplemental36-8438

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CRAFT BREWERY & DISTILLERY SUPPLEMENTAL APPLICATION
SUBMISSION REQUIREMENTS
• Completed, signed, and dated PHLY Craft Beverage Supplemental Application
• Completed ACORD Application(s) for all lines of coverage being requested
• Currently valued insurance company loss runs for current policy period plus three (3) prior years
• Brochure and advertising materials
• Color photos of brewing/ distilling equipment and storage area
• Resume of owner and/or brew master/head distiller, and business plan including financials for operations in
business less than three (3) years
APPLICANT INFORMATION
Applicant Name:
Website Address:
Year Established:
FEIN:
Liquor License Number:
Association Memberships Held:
Risk Management Contact:
Risk Manager Phone:
Risk Manager Email:
SECTION I - PRODUCTION & REVENUE INFORMATION
Barrels produced prior year:
Revenues prior 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 (Grolers, 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 distribution area?
3.
Does the Applicant distribute any products themselves?
Yes
No
If yes, number of vehicles used:
Radius of travel:
Craft Brewery and Distillery
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4.
Does the Applicant export any product?
Yes
No
If yes, what percentage of sales: %
To what countries:
SECTION II - POLICIES & PROCEDURES
1.
Does the Applicant have a formal Product Recall Plan in place?
Yes
No
2.
Has the Applicant ever had a product contamination incident or had to recall a product?
Yes
No
If yes, provide details, including cost incurred:
3.
Does the Applicant currently have Product Contamination or Recall Insurance?
Yes
No
If yes, what limits and deductible: $
Deductible: $
If yes, who is the carrier:
Does the Applicant have knowledge of any fact or circumstances which may lead to a claim under
the proposed insured?
Yes
No
4.
How are the Applicant’s products identified as an item you have produced?
5.
How long are production records maintained:
a.
Is this longer than the life expectancy of the product?
Yes
No
6.
Does the Applicant maintain product records on the following:
a.
Raw materials
Yes
No
b.
Quality controls records
Yes
No
c.
Raw material suppliers information
Yes
No
d.
Purchasers information
Yes
No
7.
Is a batch code system utilized?
Yes
No
a.
Is this system able to trace back to raw materials?
Yes
No
8.
Does the Applicant have a formal Quality Assurance program?
Yes
No
9.
Does the Applicant have a formal Supply Assessment program of its suppliers?
Yes
No
10.
Does the Applicant perform audits on its’ suppliers’ Quality Assurance procedures?
Yes
No
11.
Is the Applicant accredited with good manufacturing practices which include HACCP principals
such as SQF, FSSA 22000, or ISO?
Yes
No
12.
Are trademark investigations done prior to finalization of new products/ labels?
Yes
No
13.
Is a certificate and additional insured status required from all vendors?
Yes
No
14.
Is product testing utilized by the Applicant’s company?
Yes
No
If yes, please describe the testing procedures utilized by the Applicant’s company?
(e.g. microbiological, x-ray, metal detections, steam / heat pasteurization, irradiation)
15.
Are “test and hold” procedures utilized at the Applicant’s site?
Yes
No
16.
Does the Applicant test incoming raw materials?
Yes
No
17.
Does the Applicant import products or packaging directly from sources outside the U.S.?
Yes
No
If yes, provide details:
18.
What percentage of the Applicant’s products are packaged in glass and who are their glass
suppliers? %
Provide copies of contracts with glass suppliers.
19.
Are there any oral or written agreements in place with the Applicant’s glass suppliers that bar the
Applicant or their insurer from seeking redress against glass suppliers or otherwise limit the
Applicant’s liability in any way to glass suppliers?
Yes
No
20.
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
Craft Brewery and Distillery
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SECTION III - BREWING / DISTILLING AND REFRIGERATION EQUIPMENT
1.
Was the equipment purchased new?
Yes
No
2.
What is the barrel capacity of the equipment?
3.
Please provide details of the sanitation procedure:
4.
What country(ies) was the brewing/ distilling equipment manufactured in:
5.
Is there a regular service plan in place for all brewing/ distilling and refrigeration equipment?
Yes
No
6.
How many boilers are used at each location to provide process steam:
7.
Who is the manufacturer and what is the construction type of each boiler:
8.
What is the expiration date of each boiler’s state/ local certificate of operation:
9.
How old is the boiler and brewing equipment at each facility:
10.
Number of losses/ claims made for equipment breakdown over the past five years:
Please provide details of each event.
11.
How often is the Applicant’s equipment examined for leaks?
12.
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?
13.
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.
Is the building on any historical registry (local, state, or federal)?
Yes
No
If yes, what are the re-build requirements?
2.
Is the building over 100 years old?
Yes
No
If yes, complete a PHLY 100 Year Old Building Supplemental for each building over 100 years of age.
3.
Are there other businesses in the building?
Yes
No
If yes, list other businesses:
4.
Does the Applicant mill its own grain?
Yes
No
If yes, provide details of ventilation, dust control, and room details:
5.
Are operations conducted from a residential location?
Yes
No
6.
Is aging /storage in a separate building from the still house?
Yes
No
7.
What type of still is used?
Open System
Closed System
8.
What is the heating source of the still?
Electric
Gas
Steam
Other:
Craft Brewery and Distillery
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9.
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
10.
Pressure relief?
Yes
No
11.
Pressure monitoring alarms?
Yes
No
12.
High temperature limit alarm?
Yes
No
13.
Property Values:
Value of Brewing/ Distilling Equipment (bolted to the ground)
$
Value of Brewing/ Distilling Equipment (not bolted to the ground)
$
Value of Raw Materials on hand (average)
$
Value of Inventory (aging in barrels or fully finished)
$
SECTION V - LIQUOR LIABILITY
1.
Are all employees and volunteers TIPS, TAM or a similar alcohol awareness trained?
Yes
No
If no, what is the training procedure?
2.
Has the Applicant’s liquor license ever been revoked or suspended?
Yes
No
If yes, when and explain:
3.
Have there ever been any citations by a liquor control board?
Yes
No
If yes, when and explain:
4.
What controls are there to prevent over serving:
5.
What are the procedures for handling an intoxicated patron:
SECTION VI - BEVERAGE AND FOOD SERVICE INFORMATION
1.
Does the Applicant operate a tasting room/ restaurant?
Yes
No
If yes:
a.
What are the hours of operation:
b.
Are there drink specials or a “happy hour”?
Yes
No
c.
Number of drinks or samples allowed:
d.
Size of drinks or samples served:
e.
Seating capacity:
2.
Does the Applicant operate a kitchen?
Yes
No
If yes:
a.
What are the hours of food service:
b.
Indicate types of cooking equipment (check all that apply):
Commercial ovens
Deep fat fryers
Open flame grills
Broilers
Pizza ovens
No cooking present
Other (explain):
c.
Are cooking areas protected by a UL300?
Yes
No
Craft Brewery and Distillery
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d.
How often are grease filters cleaned:
i.
What is the cleaning method:
e.
How often is the hood and duct work cleaned:
f.
How often is the suppression system inspected and serviced:
g.
By whom is the system inspected and serviced:
h.
Do cooking appliances have automatic fuel shut-off valves?
Yes
No
i.
If there are deep fat fryers, do they have high limit switches?
Yes
No
j.
Are employees trained in the use of the extinguishing system?
Yes
No
SECTION VII - ENTERTAINMENT AND EVENT INFORMATION
1.
Is there a dance floor on the premises?
Yes
No
2.
Is there any live entertainment?
Yes
No
If yes, please explain:
3. Does the Applicant hold events at the facility? Yes No
If yes:
a. What type:
b. What is the number of people permitted:
c. What safety controls are there:
d. Are facility renters required to obtain Event Insurance and name the Applicant’s operation as
an Additional Insured?
Yes No
e. As host of events which exceed normal operations (hours, space, capacity) does the Applicant
obtain Special Events Insurance Coverage?
Yes No
4. Does the Applicant attend off premises events? Yes No
If yes:
a. What type(s):
b. Average number per year:
c. What safety controls are there:
Craft Brewery and Distillery
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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:
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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
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)
Craft Brewery and Distillery
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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 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)
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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
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)
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Application - Craft Brewery And Distillery Supplemental36-8438

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Completed 2 July 2020

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