Fillable Application - Fairs And Fairgrounds Supplemental Application36-11027

Fill Online, Printable, Fillable, Blank Application - Fairs And Fairgrounds Supplemental Application36-11027 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 - Fairs And Fairgrounds Supplemental Application36-11027

On average this form takes 165 minutes to complete

The Application - Fairs And Fairgrounds Supplemental Application36-11027 form is 22 pages long and contains:

0 signatures
50 check-boxes
637 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

Application - Event Planner36-11273
Application - Audio Visual Companies36-9968
Application - Film Production36-9969 Application - Fairs and Fairgounds Supplemental Application
Application - Craft Brewery And Distillery Renewal36-16355
Application - Film School36-9970
Application - Craft Brewery And Distillery Supplemental36-8438
Application - Waterslide-Water Park Supplemental36-10472 - 47FE2EC8
Application - Water Trampoline Supplemental36-9238
Application - Photographers - Videographers36-9971
Application - Go Kart Supplemental36-10471 - Application - Go Kart Supplemental Application
Application - Fireworks - Pyrotechnics36-10470 - Application - Fireworks - Pyrotechnics
Application - Camp Operators Renewal36-10469
Application - Film Production Short Term36-9972 Application - Fairs and Fairgounds Supplemental Application
Application - Camp Operators36-10468
Application - Bowling Center Supplemental36-11687
Application - Boat Dealers Renewal Supplemental36-8610 - Application - Boat Dealers Renewal Supplement
Application - Golf - Country Clubs36-8544
Application - Boat Dealers New Business Supplemental36-8609
Application - Audio Visual Companies36-11009
Application - Golf Ranges And Miniature Golf Supplemental36-11596

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

Redo

Arial Font

Arial
Calibri
Roboto
Open Sans

AFont color

AB
A.B
A..B
A...B
A....B

Remove Field

ADD FIELDS

FAIRS AND FAIRGROUNDS SUPPLEMENTAL APPLICATION

Pages 1 - 3 must be completed for all submissions

For Parade Coverage, please complete the parade section on page 4.

For Motorsports Event Coverage, please complete the motorsports section on page 4.

For Rodeo Event Coverage, please complete the rodeo section on page 5.

For Demolition Derby Event Coverage, please complete the demolition derby section on page 5.

For Hired and Non-Owned Auto Liability Coverage, please complete the auto section on pages 5 & 6.

For Liquor Liability Coverage, please complete the liquor section on pages 6 & 7.

For Pyrotechnics Coverage, please complete the pyrotechnics on pages 8 -10.

If you are responsible for the Security, please complete the security section pages 10 – 12.

SUBMISSION REQUIREMENTS

• Photos of fairgrounds • Financials

• Current schedule of events • Copy of emergency evacuation plans

• Current schedule of any non-fair events where

coverage is desired

• Four years of currently valued loss runs

including present year

• Copy of contract between insured and carnival

GENERAL INFORMATION

Name of Insured (as it will appear on the policy):

Address Location of Headquarters:

Telephone Number: Fax Number: Website:

Form of Business: Corporation Joint Venture Partnership LLC

Other:

Is the insured considered: For Profit Not For Profit Federal ID#:

Date of Incorporation: Chartered or Incorporated in what state?

Name of Officers:

President: Executive Director:

Insurance Chairman: Risk Manager:

1. Please provide detail on management experience:

2. Nature of operations / description of the insured:

3. Does the insured engage in any other business operations under the name of

the Insured as it will appear on the policy? Yes No

If “yes,” please explain:

4. Proposed Effective Date:

5. Estimated # of events:

Fairs and Fairgrunds Supplemental

Page 1 of 14

06/2017

Print Application

Clear Application

UNDERWRITING INFORMATION

1. Please list all additional insured and their relationship:

2. Location for fair site:

3. Is this premises owned by the Named Insured? Yes No

4. Total Acreage:

5. Fair Dates:

6. How many years has this fair been under current management?

7. Estimated total attendance? Estimated daily attendance:

8. Does your operation include boarding of animals other than during the fair? Yes No

If “yes,” please explain:

9. Is there any overnight public campgrounds? Yes No

If “yes,” how may spaces?

10. Is there 24 hour security? Yes No

11. Are there rules and regulations posted for campers? Yes No

12. Who is providing the security for the fair?

13. If contracted, is a certificate of insurance collected? Yes No

14. Is security armed? Yes No

15. Who is responsible for medical personnel?

16. Distance to nearest hospital:

17. Is there an ambulance on site? Yes No

18. Are there any other medical facilities on site? Yes No

19. Are there formal emergency evacuation plans in place? Yes No

If “yes,” please provide a copy.

20. How is the crowd notified?

21. How is the crowd dispersed from fair and surrounding areas?

22. Is there musical entertainment provided? Yes No

If “yes,” what type: Hard Rock Pop Rock Jazz

Country & Western Classical Blue Grass

Other:

23. Do professional players hold the Named Insured harmless with regards to

injures?

Yes No

24. Number of Grandstands:

Year Built:

Construction Type:

Guardrails: Yes No

25. Number of Bleachers:

Year Built:

Construction Type:

Guardrails: Yes No

26. Do you have a documented maintenance and inspection program for the

Grandstands / bleachers? Yes No

27. Date of last inspection:

28. Does the fair contract with a carnival for amusement rides? Yes No

29. If “yes,” do you collect a certificate of insurance? Yes No

Fairs and Fairgrunds Supplemental

Page 2 of 14

06/2017

Print Application

Clear Application

PARADES N/A

1. Date of parades:

2. Hours of parades:

3. Are all roads closed in both directions? Yes No

4. Number of floats:

5. Number of equestrian:

6. Number of bands:

7. Number of motorized vehicles:

8. Number of participants:

9. Are the animals insured against third-part liability claims by the owner? Yes No

10. What is the minimum limit required to be carried?

MOTORSPORTS EVENT APPLICATION N/A

Club Association or Promoter:

Address:

Contact: Phone:

Event Dates:

1. Event is held: Outdoors Indoors

2. Facility Name:

3. Facility Address:

4. Type of event:

5. Other ancillary attractions:

6. Are you requesting participant coverage? Yes No

Special Instr

uctions:

7. Are there guardrails? Yes No

If “yes,” type of material used:

8. Height:

9. Distance apart:

10. Is the guardrail in front of all spectator areas? Yes No

If “yes,” type of material used:

11. Are all spectators restricted to the grandstands? Yes No

12. Grandstand Construction:

13. Seating Capacity:

14. Estimated Attendance:

15. Length of Show:

16. Is there an ambulance present? Yes No

17 Fire Extinguishers? Yes No

18. Number and type of security present?

Fairs and Fairgrunds Supplemental

Page 3 of 14

06/2017

Print Application

Clear Application

RODEO EVENT APPLICATION N/A

1. Name of rodeo promoter / company / contractor:

2. Does the rodeo sign a contract holding the insured harmless with respect to claims

arising from the operation of the escape of rodeo stock? Yes No

3. Does the rodeo provide a certificate of insurance naming insured as an additional

insured? Yes No

4. What limits are required to be carried by rodeo?

5. Is the stock boarded overnight at insured’s facility? Yes No

6. Are the transfer areas between the animal pens / stalls and rodeo competition area

restricted from the general public?

Yes No

7. Rodeo Dates:

8. Estimated Attendance:

9. Facility Location:

10. Rodeo is: Indoors Outdoors

11. Rodeo is: Permanent Temporary

12. Is there an arena fence / barrier? Yes No

13. If “yes,” what is the construction:

14. What type of spectator seating is provided? Grandstand Temporary Bleachers

DEMOLITION DERBY EVENT APPLICATION N/A

1. Name of demolition derby promoter / company / contractor?

2. Does the derby provide a certificate of insurance naming insured as an additional

Insured? Yes No

3. What limits are required to be carried by derby?

4. Are the vehicles stored overnight at insured’s facility? Yes No

5. Demolition Derby Dates:

6. Estimated Attendance:

7. Facility Location:

8. Derby is: Indoor Outdoors

9. Derby is: Permanent Temporary

10. Is there a fence / barrier? Yes No

11. If “yes,” what is the construction:

12. What type of spectator seating is provided? Grandstand Temporary Bleachers

NON-OWNED AND HIRED AUTO LIABILITY N/A

1. Does the insured have any owned automobiles? Yes No

2. If “yes,” who is the insurer?

3. Limits of coverage:

4. Effective date of coverage:

5. Do you allow employees to use their own personal vehicles for your business purposes? Yes No

If “yes,” how many employees use personal vehicles?

If “yes,” how often? Daily Weekly Monthly Other:

6. Do you have a driver screening program for those employees who use their own

personal vehicles for your business purposes?

Yes No

7. Do you obtain Motor Vehicle Reports? Yes No

If “yes”, how often? Annually Every other year Other:

8. Do you confirm that all employees who regularly use their cars for business purposes

carry minimum personal auto limits?

Yes No

9. If “yes,” what minimum limits are required?

10. Please provide the approximate cost of hire for all hired or leased autos during the course of the policy

period: $

Fairs and Fairgrunds Supplemental

Page 4 of 14

06/2017

Print Application

Clear Application

11. Do you have a driver training program for employees who use owned vehicles or their

own personal vehicles?

Yes No

12. Limits of coverage required:

$100,000 $300,000 $500,000 $1,000,000 Other: $

13. Is hired auto physical damage required? Yes No

If “yes,” what is the maximum value of hired vehicle you would like to insure? $

14. What deductible level would you like? $250 $500 $1,000 Other:

LIQUOR LIABILITY N/A

1. Name on liquor license:

2. Liquor License Number: Class of License:

3. Type of facility or event where liquor will be sold:

4. Dates coverage required:

5. Opening and closing hours of event (s):

6. Opening and closing hours of liquor sales:

7. Has applicant’s liquor license ever been revoked or suspended? Yes No

If “yes,” please explain:

8. Has applicant incurred claims for liquor liability during the last 3 years? Yes No

If “yes,” please explain:

9. Has any insurer cancelled or non-renewed coverage during the last 3 years? Yes No

If “yes,” please explain:

10. Has applicant ever been fined by alcoholic beverage control or other governmental

regulator?

Yes

If “yes,” please explain:

11. Type of beverages sold:

12. Annual Gross Sales:

Liquor Sales: $

Food Sales: $

Other: $

13. Are patrons allowed to carry alcoholic beverages onto the premises? Yes No

If “yes,” what type:

14. Do you exercise the right of search and seizure of contraband items? Yes No

If “yes,” how do you notify the public of this?

15. Do you maintain security personnel at entry check points? Yes No

If “yes,” what type?

Fairs and Fairgrunds Supplemental

Page 5 of 14

06/2017

Clear Application

Print Application

16. Are the alcohol sales and consumption:

Contained within one fixed site, or Are booths/stands located throughout the event site?

17. Number of servers used?

Professionals? Yes No Explain:

Volunteers? Yes No Explain:

18. Do the servers receive any type of alcohol awaren

ess training? Yes No

If “yes,” please explain:

19. Median age of liquor customers: 21 - 25 25 - 30 30 - 40 40 and over

20. Are minors allowed to enter the location where alcohol is being served? Yes No

If “yes,” how is underage consumption of alcohol prevented?

21. Explain how ID’s are checked:

22. Are unformed police officers present at the site of alcohol sales? Yes No

If “yes,” how many?

23. Are undercover police officers present? Yes No

If “yes,” how many?

24. Are private security officers present? Yes No

If “yes,” how many?

25. Are rule

s and regulations clearly displayed for patrons viewing? Yes No

Describe:

26. In what size container is the alcoholic beverage served?

Cup oz.

Pitcher Other:

27. Is there a limit placed on the quantity of alcoholic beverages purchased at one time? Yes No

Explain:

28. Is there entertainment provided? Yes No

29. Live Music? Yes No

30. Disc Jockey? Yes No

31. Type of Music:

32. Is the parking area patrolled to prevent intoxicated drivers from leaving the premises? Yes No

Explain:

33. Is there any type of designated driver program? Yes No

Explain:

34. Is there any other underlying liquor liability coverage being provided? Yes No

Explain:

35. Will there be additional limits of liquor liability purchased? Yes No

If “yes,” what is the additional limit? $

Fairs and Fairgrunds Supplemental

Page 6 of 14

06/2017

Print Application

Clear Application

PYROTECHNICS N/A

1. Limit of liability requested: $1,000,000 Other: $

2. Description of Events:

3. Location of Events:

4. Date of Events:

5. Who has the Authority having jurisdiction over the use of pyrotechnics at your facility?

Local Fire Department State Fire Marshal Other (Please list):

6. What permit process must be followed prior to use of pyrotechnics at your facility:

7. Have you staged pyrotechnic displays before? Yes No

If “yes,” please list any claims/losses that have occurred and the amount of loss:

Description Date of Occurrence Amount of Loss

8. Who will be the pyrotechnics operator?

Named Insured Contractor

Complete this section if the Pyrotechnics Operator is the Named Insured

1. List names of people shooting fireworks and describe their experience.

Please note: This coverage will exclude Bodily Injury Liability to the fireworks shooter.

Name Experience

2. Where are the pyrotechnics stored when not in use?

3. Does it meet Federal/State Storage Regulation? Yes No

4. What quantity of pyrotechnic material is stored on site (pounds, # of shows, etc):

Describe the type and amount of pyrotechnics used in recurring events (e.g. facility introductions,

home runs, etc.):

6. Describe what fire prevention and suppression measures are taken to support the

pyrotechnic loading and firing process:

7. Do you secure proper pyrotechnic permits for each event? Yes No

8. Are the shooters listed above licensed for pyrotechnics? Yes No

Fairs and Fairgrunds Supplemental

Page 7 of 14

06/2017

Clear Application

Print Application

Complete this section if the Pyrotechnics Operator is a Contractor.

1. Name:

2. Is there an agreement with the contractor? Yes No

If “yes,” please provide a copy of the agreement.

3. Will liability coverage be provided by the pyrotechnics contractor? Yes No

If “yes,” please indicate limits of coverage provided:

$1,000,000 Greater than $1,000,000 Other:

Please attach a copy of certificate of insurance including any additional insured listing.

4. Do you confirm that the contractor has secured the proper pyrotechnic permits for each

event? Yes No

5. Describe what fire prevention and suppression measures are taken to support the pyrote

chnic loading and

firing process:

6. Do you allow tenant users (including temporary tenant users) to conduct

pyrotechnic displays either

themselves or through a contractor?

Yes No

If “yes,” what steps are taken to ensure that the appropriate permits are g

ranted, appropriate fire safety

codes are me

t, and that insurance has been obtained from either the tenant or the tenant’s contractor

which lists you as an Additional insured?

If “no,” does the tenant lease/use agreement indicate that pyrotechnic di

splays

are not permitted?

Yes No

7. Are events with pyrotechnics held:

Indoors Outdoors

8. What type of pyrotechnics will be displayed (as defined in NFPA code 1126)?

Aerial Shells Airbursts Black Powder Comets

Concussion Effects Concussion Mortars Electric Matches Flares

Flash Pots Flashpowder Gerbs Integral Mortars

Mines Mortars Rockets Saxons

Salutes Wheels Waterfall, Falls, Park Curtains

Other, please list:

OUTDOOR PYROTECHNICS N/A

(only complete if outdoor pyrotechnic displays are staged)

9. Are the events in compliance with NFPA 1123 or 1126 (Code for Fireworks Display)? Yes No

10. Is there fencing to keep spectators away from restricted areas during the fireworks

sho

oting?

Yes No

If “yes,” distance of spectator fencing from launch site:

Distance of spectator parking area from launch site:

Distance of closest building or structure from launch site:

11. Will there be firefighting equipment on site during the event? Yes No

If no firefighting equipment on site, give distance to nearest fire station:

12. Will you have an ambulance on site? Yes No

If “no,” what is the estimated response time of an ambulance?

If “no,” what is the distance to nearest medical facility:

Fairs and Fairgrunds Supplemental

Page 8 of 14

06/2017

Print Application

Clear Application

INDOOR PYROTECHNICS N/A

(only complete if indoor pyrotechnic displays are staged)

13. Are the events in compliance with NFPA 1126 (Standard Code for the Use of

Pyrotechnics before a Proximate Audience)?

Yes No

14. Is the facility sprinklered? Yes No

15. What other form of fire fighting equipment is available at the facility:

16. Does the facility have an emergency evacuation plan? Yes No

If “yes,” how often is the staff drilled on emergency evacuation:

17. Number of accessible (not locked) emergency exits at the facility:

18. What steps are taken to inform patrons of the locations of all emergency exits?

19. Maximum capacity of the facility:

20. Has the fire marshal approved the use of pyrotechnics at the facility? Yes No

If “yes,” as of what date:

SECURITY COVERAGE N/A

PART I:

1. Who is primarily responsible (via contract) for liability coverage for security personnel?

Insured Municipality Sub-contractor

2. Number of security personnel on staff:

3. Number of security supervisors:

4. Number on premises:

5. Number off premises:

6. Do any security personnel carry a firearm as part of their equipment while on duty? Yes No

7. Are the security persons employed or contracted by the park?

Employed Contracted

("Employed" means the individual is being paid and supervised directly by the insured. "Contract" means the

existence of a written contract with another entity for security services that has insurance coverage separate from the

insured's policy for security liability.)

Note: If "Employed," please answer Section B., Part I, II, III, and V.

If "Contracted," please answer Section B., Part I, II, III, IV, and V.

If applicable, please provide the estimated payroll for employed security persons: $

8. Total maximum hours per day permitted at this and all other places of employment:

9. Total maximum hours per week:

10. What are the staffing guidelines per number of patrons?

11. Are the guidelines determined by: Ordinance, or Statute

12. Industry standard? Yes No

Other (please describe):

Fairs and Fairgrunds Supplemental

Page 9 of 14

06/2017

Print Application

Clear Application

PART II:

1. Is there a pre-employment screening procedure? Yes No

If “yes,” please describe:

2. Does the procedure include contacting previous employers over the previous five

years?

Yes No

3. Do you contact at least three personal references? Yes No

4. Is a psychological screening profile used? Yes No

If "yes," what type:

5. Is a criminal background check made? Yes No

If "yes," what agency is used for the criminal background check?

Is completion of a minimum 20 hours initial training program required before

deployment? Yes No

7. Who conducts the training and what are the trainers qualifications:

8. Is a minimum of 10 hours on-site training required? Yes No

Is a minimum of 4 hours of annual refresher or continuing education training

planned and conducted for each security employee? Yes No

10. Is each security person given a personal copy of the training/safety manual? Yes No

If "yes," has each security person given the park written acknowledgment of the

policies and contents? Yes No

Note: PLEASE INCLUDE A COPY OF THE MANUAL & A SAMPLE OF THE WRITTEN

ACKNOWLEDGMENT.

PART III:

1. Are the security personnel in uniform? Yes No

If "yes," please describe the uniform:

Note: PLEASE ATTACH A PHOTOGRAPH OF ONE SECURITY PERSON IN STANDARD UNIFORM.

2. Are the security personnel identified by other than a uniform? Yes No

If "yes," please describe the identification and include an example or Photograph.

3. Please indicate any equipment carried or routinely available to security personnel:

Flashlight Type: Size: Construction:

Handcuffs First Aid Kit (including blood borne pathogen kit)

Night Stick Is Night Stick Police Regulation or Other?

Taser/Phaser Chemicals (Mace, pepper gas) Other:

Firearm - Caliber: .357 .38 .9mm Other:

Make: Colt S & W Ruger Other:

Covered Holster Type:

Is Ammunition Standard Other:

4. Firearm and ammunition approved and inspected by park or security company? Yes No

5. Describe capabilities of each guard for constant communications with each other, the

supervisor, and park management:

6. Are dogs used in your security operations? Yes No

If “yes,” please provide the type of dog(s), number, and describe duties.

Fairs and Fairgrunds Supplemental

Page 10 of 14

06/2017

Clear Application

Print Application

PART IV:

1. Date the contracting company began business:

2. Is there a written agreement with contracting company? Yes No

If "yes," please enclose a complete copy of the written agreement.

3. Name of contracting company's liability insurance carrier:

4. Is the park an additional insured on that policy? Yes No

If "yes," please enclose a complete copy of the policy.

5. Is there an established working relationship with local law enforcement? Yes No

If "yes," please describe:

Please attach a copy of the contracting company's employment procedures.

6. Number of contracted security personnel:

7. Number of security supervisors:

8. Are there any suits or legal actions pending against the company? Yes No

If “yes,” please explain in detail:

9. Is there a procedure to immediately report all incidents to park? Yes No

If “yes,” please describe:

PART V:

1. Does the supervisor make personal contact with each security person at least

once during e

ach shift?

Yes No

If "yes," please describe:

Please explain all "no" answers.

Fairs and Fairgrunds Supplemental

Page 11 of 14

06/2017

Print Application

Clear Application

DIRECTORS & OFFICERS / EMPLOYMENT PRACTICE LIABILITY

N/A

THIS SECTION IS AN APPLICATION FOR A CLAIMS MADE POLICY.

PLEASE READ YOUR POLICY CAREFULLY.

DIRECTORS & OFFICERS LIABILITY INFORMATION

Does the Applicant have a tax-exempt status under the U.S. Internal Revenue Code?

Yes

If no, provide an explanation:

FINANCIAL INFORMATION

CURRENT FISCAL YEAR

PREVIOUS FISCAL YEAR

Total Assets:

Net Assets / Fund Balance:

Annual Revenue:

Net Revenue:

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 /

Non-Profit

I.E.: ABC Foundation / Charitable Foundation

100%

01/01/2000

Non-Profit

Additional entities listed by attachment

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

Any disciplinary action by any regulatory agency or association?

Yes

Any administrative proceeding charging violation of a federal or state law or regulation?

Yes

Any other criminal actions?

Yes

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

If yes, please attach details.

EMPLOYMENT PRACTICE LIABILITY INFORMATION:

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:

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:

Does the Applicant have an employment handbook that includes an “At Will” statement?

Yes

Does the Applicant use an employment application for every potential employee?

Yes

Does the Applicant use outside employment counsel for employment advice?

Yes

Does the Applicant have a full time, dedicated human resource staff?

Yes

Fairs and Fairgrunds Supplemental

Page 12 of 14

06/2017

Clear Application

Print Application

Total number of current employees with annual compensation greater than $100,000:

CURRENT COVERAGE:

COVERAGES

Insurance Company

Limit of

Liability

Deductible

Policy Effective

Dates

Premium

D & O

EPLI

Fiduciary

Workplace

Violence

Internet Liability

WARRANTY INFORMATION:

With respect to this coverage, has any Underwriter refused, canceled or non-renewed

coverage? (Not Applicable in Missouri)

Yes

If yes, please provide details:

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 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.

Fairs and Fairgrunds Supplemental

Page 13 of 14

06/2017

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

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)

Fairs and Fairgrunds Supplemental

Page 14 of 14

06/2017

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 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)

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

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).