Fillable Application - Family Entertainment Centers %28FEC%2936-11594

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Application - Family Entertainment Centers %28FEC%2936-11594

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FAMILY ENTERTAINMENT CENTER (FEC) APPLICATION
SECT
ION I - III MUST BE COMPLETED FOR ALL SUBMISSIONS
For Abuse and Molestation coverages, complete section V
For Liquor Liability coverage, complete section VI
For Hired and Non-Owned Auto coverage, complete section VII
SUBMISSION REQUIREMENTS
•
Complete ACORD Property, Auto and Umbrella Liability if coverages requested
•
Currently valued insurance company loss runs for the current policy period plus three (3) prior years
•
Web site information, brochures and photos
•
Facility diagram
•
Ride Inspection forms
•
Employee training manual
•
Latest financial statement
•
Emergency evacuation plan
•
Copy of waivers and releases where required
•
Copy of safety rules
•
Certificates of Insurance from any sub-contractors / independent contractors, if any
SECTION I - GENERAL INFORMATION
1.
Applicant name:
2.
Name of facility:
3.
Mailing address:
City:
County:
State:
Zip:
Physical address:
County:
State:
Zip:
4.
Contact person:
Telephone:
Contact e-Mail address:
Web address: www.
5.
Risk Management Contact:
Risk Management’s Phone:
Risk Management eMail:
6.
Business type:
Corporation
Partnership
Individual
Non-Profit
Governmental entity
Other:
7.
Year business was established? Number of years under present management:
FEIN:
8. Is the Applicant’s business part of a franchise? Yes No
If yes, what is the name of the franchise?
9. Does the Applicant have a safety manager on premises at all times the facility is open? Yes No
If yes, provide name and contact information:
10. Does the Applicant have a formal safety training program for employees? Yes No
Family Entertainment Center (FEC)
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SECTION II - PREMISES INFORMATION
1.
Average annual attendance: Operating season: to
Annual payroll: $ Number of employees:
SALES / RECEIPTS
a.) Amusements
$
b.) Food and beverage
$
Describe:
c.) Beer and liquor sales
$
d.) Parking
$
e.) Souvenirs / Novelties
$
Describe:
GENERAL INFORMATION (Explain any “yes” answers in REMARKS section below.)
2.
Any medical facilities provided or any employed physicians / nurses?
Yes
No
3.
Any storage, treating, discharging, applying, disposing or transporting hazardous materials?
Yes
No
4.
Any operations sold, acquired or discontinued in the last five (5) years?
Yes
No
5.
Machinery, equipment or attractions rented to others?
Yes
No
6.
Any watercraft docks (not bumper boats), floats on premises?
Yes
No
7.
Is there a swimming pool on premises?
Yes
No
8.
Are all swimming pools and spas compliant with Virginia Graeme Baker Pool and Spa Safety
Act? If no, provide time table and action plan:
Yes
No
9.
Any special events scheduled throughout the year?
Yes
No
10.
Does the Applicant own or lease the facility:
Own
Lease
If leased, provide a copy of leasing agreement.
11.
If leased, who is responsible for parking areas:
Owner
Insured
12.
If leased, who is responsible for building maintenance:
Owner
Insured
13.
Any structural alterations contemplated?
Yes
No
14.
Any demolition contemplated?
Yes
No
REMARKS:
SECTION III – LIFE SAFETY
1. Does the Applicant have an automatic extinguishing system over deep fat fryers, grills &
stoves? Yes No
How often are hood / ducts cleaned:
By whom:
Insured
Sub-contractor
If by sub-contractor, how often are they serviced: Date last serviced:
2.
Central station fire alarm?
Yes
No
3.
Central station burglar alarm?
Yes
No
4.
Surveillance cameras?
Yes
No
5.
Does the Applicant have an Automated External Defibrillator(s)(AED)?
Yes
No
If yes, are staff members trained to use it?
Yes
No
6. Does the Applicant have backup emergency lighting and / or emergency generators in the
event of a power failure?
Yes
No
7.
Does the Applicant have an emergency evacuation plan? (If yes, attach a copy)
Yes
No
8.
Are evacuation procedures and floor plans posted?
Yes
No
9.
Are parking lots well lit?
Yes
No
10.
Patrolled by security?
Yes
No
11.
Does the Applicant provide live entertainment? If yes, describe type and how often:
Yes No
Family Entertainment Center (FEC)
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RIDES / ATTRACTIONS
1. Do all ride signs comply with manufacturer recommendations with regard to age, height and
exit requirements?
Yes
No
2. Does the Applicant or has the Applicant ever manufactured or retro-fitted any amusements /
attractions?
Yes
No
If yes, provide a list of all such attractions and the changes made.
3.
Are periodic inspections required by state inspectors?
Yes
No
4.
Are all required state, county, and/or local licenses or permits current?
Yes
No
Date of latest inspection: Permit expiration date:
5.
Has insured ever received a citation for violation of licensing or permit requirements?
Yes
No
6.
Are rides inspected daily?
Yes
No
7.
Is inspection log maintained?
Yes
No
8.
Are maintenance manuals for all rides kept on premises?
Yes
No
9.
Is there a qualified maintenance staff on site?
Yes
No
10.
Is there an on-site maintenance shop?
Yes
No
11.
Is there adequate maintenance equipment on site?
Yes
No
12.
Are there rides where the operator controls the speed?
Yes
No
If yes, provide a list and operator training required.
SECTION IV - OPERATIONS
Bumper Boats
Annual Receipts:
$
How many:
Manufacturer:
Number of operators:
Height of observation fence:
ft.
Age / Height limit – At least ten (10) years and 48”?
Yes
No
Depth of water four (4) feet or less?
Yes
No
Maximum engine horse power:
hp
Bumper Cars
Annual Receipts:
$
How many:
Manufacturer:
Minimum height requirement: in.
How many attendants:
Type of seat belt:
Cars equipped with dash and headrest pads?
Yes
No
Wheel pads on steering wheels?
Yes
No
Batting cages (WAIVER AND RELEASE REQUIRED)
Annual Receipts:
$
How many:
Manufacturer:
Min. age requirement:
Mfg. age / speed recs. posted?
Clearly marked for right or left handed hitters?
Yes
No
Are home plates clearly marked?
Yes
No
Machine velocity checked or calibrated?
Yes
No
If yes, by whom?
Are records kept?
For how long?
Are pitching machine settings able to be altered by hitters?
Yes
No
Helmet or other safety equipment required to be used by participants in cages?
Yes
No
Light or similar indicator when last ball has been pitched?
Yes
No
Coin Operated Amusements
Annual Receipts:
$
How many:
Number of attendants:
Equipment is:
Owned
Leased
Are machines properly grounded?
Yes
No
Is there an on-site maintenance shop?
Yes
No
Is there adequate maintenance equipment on-site?
Yes
No
Coin Operated rides
Annual Receipts:
$
How many?
Describe:
Family Entertainment Center (FEC)
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Driving Ranges
Annual Receipts:
$
Number of stalls:
Partitions between stalls?
Yes
No
Escape Rooms
Annual Receipts:
$
Are escape rooms locked?
Yes
No
Can employees view all participants in all game sections by surveillance cameras and / or by
employees on the gaming floor?
Yes
No
Are all rules explained to participants prior to entering the escape room?
Yes
No
Does the Applicant provide actors?
Yes
No
If yes, please describe:
Are any tasks physical by nature that could potentially cause injury?
Yes
No
If yes, please describe:
Is there a participant panic button or way to stop the game in case of emergency?
Yes
No
If yes, please describe:
Go Karts (WAIVER AND RELEASE REQUIRED FOR KARTS
WITH SPEEDS OVER 21 MPH)
Annual Receipts:
$
How many?
Number of tracks:
Maximum speed: mph
Indoor / outdoor:
Max. number on track any one time:
Number of attendants:
Are all go karts assembled and maintained to meet the manufacturer’s specifications / instructions?
Yes
No
In addition, is a maintenance program in place with logs of all maintenance done to each go kart?
Yes
No
Gas Electric Minimum age: Minimum height:
Seat belts required?
Yes
No
Equipment with governors to control speed?
Yes
No
Equipped with roll bars and bumper guards?
Yes
No
Are all Go Karts equipped with the following:
Padded steering wheel
Yes
No
Padded head rest
Yes
No
Safety/seat belts for each seat
Yes
No
Wheel enclosures
Yes
No
Maximum speed of 10 miles per hour
Yes
No
Operator cut off system?
Yes
No
Are participants at least 48” tall and at least eight years of age?
Yes
No
Are participants required to wear shoes, helmets, and seat belts?
Yes
No
Are safety and operation rules posted in plain sight?
Yes
No
Track rules clearly and prominently posted?
Yes
No
Are there signs posted stating that there is no racing, bumping or reckless driving permitted?
Yes
No
Outdoor tracks fenced?
Yes
No
Fences meet American Society for Testing and Materials (ASTM) F-24 requirements?
Yes
No
Are any obstacles within thirty (30) feet of track padded or removed for safety?
Yes
No
Is there a minimum of two (2) qualified staff members on the track during go kart activities?
Yes
No
Inflatables / Bounce and Play
Annual Receipts:
$
Describe:
Does the Applicant have any outdoor inflatables?
Yes
No
Note – Off premises use or rental of inflatables is excluded.
Miniature Golf
Annual Receipts:
$
Number of courses:
Number of holes:
Waterfalls or fountains?
Yes
No
Do they have ground fault interrupters?
Yes
No
Family Entertainment Center (FEC)
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Paintball / Laser Tag (WAIVER AND RELEASE REQUIRED)
Annual Receipts:
$
Minimum age: Minimum height: Maximum participants per game:
Ratio of judges to participants:
Can employees view all participants in all game sections by surveillance cameras and / or by
employees on the gaming floor?
Yes
No
Is there written instructions, procedures and training provided for participants?
Yes
No
Does equipment meet American Society for Testing and Materials (ASTM) standards?
Yes
No
Specify types of air fills used:
Are safety plugs mandatory?
Yes
No
Does the Applicant repair or modify equipment sold?
Yes
No
Is there a scheduled maintenance plan for equipment?
Yes
No
If yes, provide details
Do manufacturers provide certificates of insurance including you as additional insured?
Yes
No
Are participants separated by level of experience?
Yes
No
Are spectators properly protected from the paintball area / field?
Yes
No
Are participants in violation of the safety rules ejected?
Yes
No
List protective gear supplied to participants:
Indicate feet per second used at your location:
How often is equipment inspected:
How often is equipment changed:
Facility endorsed or fenced?
Yes
No
Any barriers or obstacles?
Yes
No
If yes, please describe or provide diagram:
Any hand to hand fighting allowed?
Yes
No
Are customers allowed to bring their own equipment?
Yes
No
If yes, is equipment and velocity checked?
Yes
No
Is eye protection required?
Yes
No
Are employees trained in first aid?
Yes
No
Rock Climbing Wall (WAIVER AND RELEASE REQUIRED)
Annual Receipts
$
Does rock wall meet all Climbing Wall Industry Group (CWIG) standards and local codes?
Yes
No
What is the height of the wall:
Bouldering (traversing) wall only – 6’ or less?
Yes
No
Are participants allowed to climb on their own?
Yes
No
What is the check in procedure:
What kinds of verbal contacts or warnings given:
When is safety testing done:
What type certification system is used:
What type of equipment is used? Describe the belay system.
What type of landing surface is used – describe makeup, thickness and extent of fall protection:
Who is responsible for daily maintenance and checks:
Are spotters required?
Yes
No
At what height:
If yes, what is frequency of use off premises:
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Miscellaneous Activities
Number of Participants
Annual Receipts
Euro bungee
$
Trampolines
$
Rope ladders
$
Mechanical bull
$
Shuffleboard
$
Volleyball / Basketball
$
Tennis courts
$
Billiard / Pool table
$
Simulators
$
SECTION V - ABUSE AND MOLESTATION N/A
1.
Does the Applicant’s current insurance program include Abuse and Molestation coverage?
Yes
No
2.
Does the Applicant’s employment process (for employees and volunteers) include verification
of whether the individual has ever been convicted of any crime, including sex-related or child
abuse related offenses, before an offer of employment is made?
Yes
No
3.
Does the Applicant verify employment references for employees and volunteers?
Yes
No
4.
Does the Applicant conduct personal interviews?
Yes
No
5.
Are formal written procedures in place for hiring? (If yes, attach a copy)
Yes
No
6.
Is there a written supervision plan that monitors staff in day-to-day relationships with clients,
both on and off premises? (If yes, attach a copy)
Yes
No
7.
Does the Applicant have a written crisis plan for dealing with employees, volunteers, victims,
parents, authorities and the media if you have an incident of abuse? (If yes, attach a copy)
Yes
No
8.
Have any incidents resulted in an allegation of sexual abuse?
Yes
No
If yes, was the case settled?
Yes
No
Was the case taken to trial?
Yes
No
Amount paid for damages to the victim: $
Does the Applicant’s state allow criminal background checks?
Yes
No
If yes, does the Applicant run criminal background checks prior to hire for:
Employees?
Yes
No
Volunteers?
Yes
No
SECTION VI – LIQUOR N/A
1.
Is liquor license in the Applicant’s name?
Yes
No
If no, what is the name on the license and their relationship to the Applicant:
Liquor license number:
Class of license:
2.
Is the liquor service sub-contracted to a third party?
Yes
No
If yes, provide limits of liability maintained by the sub-contractor: $
Is the Applicant listed as Additional Insured under sub-contractors liquor liability coverage?
Yes
No
Is contingent liquor liability coverage requested by Insured?
Yes
Yes
No
3.
Has the Applicant’s liquor license ever been revoked or suspended?
No
If yes, explain:
4.
Has the Applicant incurred claims for liquor liability during the last three (3) years?
Yes
No
If yes, explain:
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5.
Has any insurer cancelled or non-renewed coverage during the last three (3) years?
Do not
answer if located in Missouri.
Yes
No
If yes, explain:
6.
Has the Applicant ever been fined by Alcoholic Beverage Control or other
Governmental regulator?
Yes
No
If yes, explain:
7.
Type of beverages sold:
8.
Are patrons allowed to carry alcoholic beverages onto the premises?
Yes
No
If yes, what type:
9.
Does the Applicant exercise the right to search and seizure contraband items?
Yes
No
If yes, how does the Applicant notify the public of this:
10.
Does the Applicant maintain security personnel at entry check points?
Yes
No
If yes, what type:
11.
Are the alcohol sales and consumption contained within one fixed site, or are
booths / stands located throughout the event site:
12.
Number or servers used:
Are they professional servers?
Yes
No
Explain:
Are they volunteer servers?
Yes
No
Explain:
13.
Do the servers receive any type of alcohol awareness training?
Yes
No
If yes, describe:
14.
Median age of liquor customers:
21-25
25-30
30-40
40 and over
15.
Are minors allowed to enter the location where alcohol is being served?
Yes
No
If yes, how is underage consumption of alcohol prevented:
16.
Explain how ID’s are checked:
17.
Are uniformed police officers present at the site of alcohol sales?
Yes
No
Are undercover police officers present?
Yes
No
Are private security officers present?
Yes
No
Average number of officers present at site:
18.
Are rules and regulations clearly displayed for patrons viewing?
Yes
No
Explain:
Family Entertainment Center (FEC)
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19.
Is there a limit placed on the quantity of alcoholic beverages purchased at one time?
Yes
No
Explain:
20.
Is the parking area patrolled to prevent intoxicated drivers from leaving the premises?
Yes
No
Explain:
21.
Is there any type of designated driver program?
Yes
No
Explain:
SECTION VII - HIRED & NON-OWNED AUTO N/A
1.
Does the Applicant have any owned automobiles?
Yes
No
NOTE:
If the Applicant has owned autos, the hired car and non-owned auto coverage should be placed with
the automobile carrier. Explain if an exception is required:
2.
Does the Applicant allow employees to use their own personal vehicles for business
purposes?
Yes
No
If yes, how many employees use their own personal vehicles?
If yes, how often?
Daily
Weekly
Monthly
Other:
3.
Does the Applicant obtain Motor Vehicle Reports?
Yes
No
If yes, how often?
Annually
Every other year
Other:
4.
Does the Applicant confirm that all employees who regularly use their cars for business
purposes carry minimum personal auto limits?
Yes
No
If yes, what minimum limits are required?
5. Please provide the approximate cost of hire for all hired or leased autos during the course of
the policy period:
6.
Is hired auto physical damage required?
Yes
No
If yes, what is the maximum value of hired vehicle the Applicant would like insured? $
NOTE: Physical Damage deductibles: $100 comprehensive / $1,000 collision provided.
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SECTION VIII - 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 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
monitoring, 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
SECTION
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)
Family Entertainment Center (FEC)
Page 10 of 12
© 2018 Philadelphia Consolidated Holding Corp.
09/2018
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
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FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge
and belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this
Application) are true and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information
in this Application changes prior to the effective date of the policy, the Applicant will notify the Company of such changes and the
Company may modify or withdraw the quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
FRAUD NOTICE STATEMENTS
ANY PERSON WH
O KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE
IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO
KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE
OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM
INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY
AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER
FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A
FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER
OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR
PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR
COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT
MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT,
FINES OR A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (P
LEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
____________________________________________________
SIGNATURE DATE
SECTION T
O BE COMPLETED BY THE PRODUCE
R/BROKER/AGENT
PRODUCER AG
ENCY
(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
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Completed 2 July 2020

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