Fillable Application - Fireworks - Pyrotechnics36-10470 - Application - Fireworks - Pyrotechnics

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Application - Fireworks - Pyrotechnics36-10470 - Application - Fireworks - Pyrotechnics

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FIREWORKS/PYROTECHNICS SUPPLEMENTAL APPLICATION*
GENERAL INFORMATION
1. Location of operation:
2. Total experience in this type of business: Years
3. Limit of liability requested: $1,000,000 Other: $
4. Description of events:
5. Location of events:
6. Date(s) of event(s):
7. Who is the authority having jurisdiction over the use of pyrotechnics at your facility?
Local Fire Department State Fire Marshal
Other: (please list)
8. What permit process must be followed prior to the use of pyrotechnics at your facility?
9. Have you staged pyrotechnic displays before? Yes No
If yes, list any claims / losses that have occurred and the amount of loss:
Description Date of Occurrence Amount of Loss
a) $
b) $
c) $
d) $
*to accompany the General Application
Named Insured:
Risk Management Contact:
Risk Management Email:
Risk Management’s Phone:
Fireworks/Pyrotechnics
Supplemental Application
Page 1 of 5
© 2018 Philadelphia Consolidated Holding Corp.
11/2018
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10. Who will be the pyrotechnics operator? Named Insured Contractor
Complete this section if the Pyrotechnics Operator is the Named Insured
11. a) List names of people shooting and describe their experience.
Please note: This coverage will exclude bodily injury liability to the fireworks shooter
Name: Experience:
b) Where are the pyrotechnics stored when not in use?
c) Does it meet federal / state storage regulation? Yes No
d) What quantity of pyrotechnic material is stored on site? (number of shows, pounds etc.)
e) Describe the type of show and amount of pyrotechnics used in recurring events:
f) Describe what fire prevention and suppression measures are taken to support
the pyrotechnic loading and firing process:
g) Does the Applicant secure proper pyrotechnic permits for each event? Yes No
h) Are the shooters listed above licensed for pyrotechnics? Yes No
Complete this section if the Pyrotechnics Operator is a Contractor
12. a) Name:
b) Is there an agreement with the contractor? Yes No
If yes, attach a copy of the agreement.
c) 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.
13. a) Does the Applicant confirm that the contractor has secured the proper
pyrotechnic permits for each event? Yes No
b) Describe what fire prevention and suppression measures are taken to
support the pyrotechnic loading and firing process:
Fireworks/Pyrotechnics
Supplemental Application
Page 2 of 5
© 2018 Philadelphia Consolidated Holding Corp.
11/2018
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c) Does the Applicant 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
granted, appropriate fire safety codes are met, 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
displays are not permitted? Yes No
d) Are events with pyrotechnics held: Indoor Outdoor
e) 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 Flashpower Gerbs Integrals Mortars
Mines Mortars Rockets Saxons
Wheels Salutes Waterfall, Falls, Park Curtains
Other, please list:
OUTDOOR PYROTECHNICS
(Only complete if outdoor pyrotechnic displays are staged)
1. Are the events in compliance with NFPA 1123 or 1126? (Code for fireworks
display) Yes No
2. Is there fencing to keep spectators away from restricted areas during the
fireworks shooting? Yes No
If yes, what is the distance of spectator fencing from launch site:
What is the distance of spectator parking area from launch site:
What is the distance of the closest building or structure from launch site:
3. Will there be firefighting equipment on site during the event? Yes No
If no firefighting equipment on site, give distance to nearest fire station:
4. Will the Applicant 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:
INDOOR PYROTECHNICS
(Only complete if indoor pyrotechnic displays are staged)
1. Are the events in compliance with NFPA 1126? (Standard code for the
use of pyrotechnics before a proximate audience)? Yes No
2. Is the facility sprinklered? Yes No
Fireworks/Pyrotechnics
Supplemental Application
Page 3 of 5
© 2018 Philadelphia Consolidated Holding Corp.
11/2018
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3. What other form of fire fighting equipment is available at the facility?
4. Does the facility have an emergency evacuation plan? Yes No
If yes, how often is the staff drilled on emergency evacuation?
5. Number of accessible (not locked) emergency exits at the facility:
6. What steps are taken to inform patrons of the locations of all emergency exits?
7. Maximum capacity of the facility:
8. Has the fire marshal approved the use of pyrotechnics at the facility? Yes No
If yes, as of what date:
Fireworks/Pyrotechnics
Supplemental Application
Page 4 of 5
© 2018 Philadelphia Consolidated Holding Corp.
11/2018
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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
SECT
ION 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)
Fireworks/Pyrotechnics
Supplemental Application
Page 5 of 5
© 2018 Philadelphia Consolidated Holding Corp.
11/2018
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