Fillable Application - Golf - Country Clubs36-8544

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Application - Golf - Country Clubs36-8544

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GOLF AND COUNTRY CLUB SUPPLEMENTAL APPLICATION
SUBMISSION REQUIREMENTS
• Completed, signed, and dated PHLY Golf and Country Club Application
• Completed ACORD Application(s)
• Currently valued insurance company loss runs for the current policy period plus three (3) prior years
• Plot plan of clubhouse, cart barn, and equipment storage buildings
•
Web site address
GENERAL INFORMATION
1.
Club Name:
2.
Number of members:
3.
Number of holes:
4.
Number of employees:
5.
FEIN:
6.
Estimated Gross Annual Receipts* for the following:
* Question six (6) does not need to be completed if an annual income statement or latest audited
financials are included in the submission.
a.
Membership dues / initiation fees
$
b.
All other fees (Greens, Golf Carts, Locker Rooms, Tournaments, etc.)
$
c.
Pro Shop revenue (if owned)
$
d.
Snack bar / restaurant receipts (other than Liquor)
$
e.
Liquor sales
$
7.
Number of rounds played per year:
8.
Amenities offered (check all that apply):
Beauty Shops
Horseback Riding
Child Care / Day Camp Service
Hunting
Baby Sitting Service
Skeet / Trap Ranges
Hotel or Guest Quarters
Private Beach
Aerobics / Fitness Center
Marina / Yacht Club
Steam Room / Saunas / Tanning Beds
Watercraft
Skiing
Other - Please describe below:
Please provide a brief description of these amenities:
9.
Do you have a PGA Professional on staff?
Yes
No
Is the Golf Professional an:
Employee
Independent contractor N/A
Is the Golf Shop:
Owned by the club
Operated independently
Does the club obtain a certificate of insurance from the Professional?
Yes
No
If operated independently what is the square footage of the leased premises:
10.
Are certificates of insurance, which include naming the club as an additional insured,
obtained and kept in file for all contracted work?
Yes
No
Golf and Country Club
Supplemental Application
Page 1 of 8
© 2017 Philadelphia Consolidated Holding Corp.
06/2017
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GOLF CARTS AND GOLF COURSE
1.
Total number of riding golf carts:
2.
Golf carts are:
Owned
Leased
3.
Where are golf carts stored:
4.
If stored under the clubhouse, is there a firewall between the ceiling of the cart
storage and the clubhouse floor?
Yes
No
5.
How powered:
Gas
Electric/Battery
6.
If gas carts, does the cart barn building have proper ventilation?
Yes
No
7.
When was the last electrical maintenance visit performed:
8.
Does the insured require a signed Golf Cart Rental Agreement for all renters of a cart?
Yes
No
9.
Does the rental agreement include the procedures for the safe use of the cart?
Yes
No
10.
Does the club have a lightning warning and notification system in place?
Yes
No
If yes, please describe:
11. A signature tree located on the club’s golf course grounds can be covered up to $50,000 per
tree. If the club has a signature tree that it would like to cover; please describe the type and
location of the tree and provide a photo.
12.
Does the club apply pesticides, herbicides, or fertilizers to its golf course grounds or is that
service provided by a contractor?
Yes
No
If contracted out, does the club obtain certificates of insurance confirming pollution liability
coverage from all contractors?
Yes
No
If the club performs the work, are all applicators certified and registered by a federal or state
agency to use pesticides, herbicides, or fertilizers?
Yes
No
MAINTENANCE EQUIPMENT
1.
Where is the maintenance equipment stored:
2.
How much value is stored at one time: $
SWIMMING POOL N/A
1.
Are all swimming pools and spas compliant with Virginia Graeme Baker Pool and Spa
Safety Act? If no, provide timetable and action plan:
Yes
No
2.
Number of pools on premises:
3.
Is the pool fenced?
Yes
No
PROPERTY
1. What is the protection class of the property:
If Protection Class is 7 or higher, what is the source of water supply:
2. Distance to closest fire hydrant:
Is the fire department: Paid
Distance to fire department:
Volunteer
3. Does the property have aluminum wiring? Yes No
If yes, has it been retrofitted with one of the PHLY approved connectors (below) by a
licensed electrician? Yes No
Indicate which one: COPALUM? Yes No AlumiConn? Yes No
Date updated:
4. Does the Applicant have any air supported or fabric roof structures on premise? (Tennis
bubbles, event tents, etc…) Yes No
Golf and Country Club
Supplemental Application
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© 2017 Philadelphia Consolidated Holding Corp.
06/2017
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4.
Number of diving boards:
Height of diving board(s):
Depth of pool at entry from the diving board(s):
If you have a diving board over three (3) meters attach a photo.
5.
Does the club have any water slides? If yes, attach a photo.
Yes
No
6.
Are lifeguards on duty?
Yes
No
If no, is a sign posted?
Yes
No
7.
Does the club sponsor swim teams?
Yes
No
Do you sponsor diving teams?
Yes
No
If yes, are waivers required?
Yes
No
Do you provide transportation?
Yes
No
SNACK BAR OR RESTAURANT N/A
1.
Operated by:
Insured
Concession
2.
If concession, does lessee provide certificates of insurance naming club as an additional
insured?
Yes
No
3.
What type of extinguishing system is installed over cooking facilities:
Does the system cover the deep fat fryers?
Yes
No
RESTAURANT / LIQUOR LIABILITY
1. Gross receipts from owned restaurant/snack bar (include liquor): $
2. Gross receipts from owned banquet/catering operation (include liquor): $
3. Gross receipts for liquor only: $
4. Liquor License Number: Name of liquor license:
5. Has liquor license ever been suspended or revoked? Yes No
If yes, please describe:
6. Has liquor coverage ever been canceled? Yes No
If yes, please describe:
7. Have there been any liquor claims in the past five (5) years? Yes No
If yes, please describe:
8. Are written procedures and training provided to employees to avoid selling to intoxicated
patrons?
Yes
No
9. Are written procedures in place for providing alternate transportation for an intoxicated patron
– Designated Driver / Call a Cab?
Yes
No
10. Have all bartenders, servers, valet drivers attended an Alcohol Awareness Training Course
(Dram Shop Liability) (TIPS / TAMS) ?
Yes
No
If training on Dram Shop Liability is provided, is it ongoing education? Yes No
DWELLING OR RENTAL PROPERTY N/A
1. Does the club have any dwellings or rental property? Yes No
If yes, please describe the use of the property:
If habitational, does the property have:
fire extinguishers? Yes No
hard-wired heat/smoke detection? Yes No
second means of egress from the property? Yes No
2. Total number of rooms in hotel / guest quarters:
Golf and Country Club
Supplemental Application
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© 2017 Philadelphia Consolidated Holding Corp.
06/2017
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3. Are rooms available to members and their guests only? Yes No
If no, please describe:
DAY CARE SERVICES N/A
1. Does the club provide day care services? Yes No
(Please note day care means child care service while parent/guardian is on the premises
of the club.)
2. What are the ages of the children?
Under Age 5 Age 6 to 10 Over 10 Years of Age
DAY CAMP SERVICES N/A
1. Does the club operate a day camp? Yes No
If yes, the following information must be completed:
2. What is the counselor to children ratio: (Ex.: 4 children per counselor)
3. Number of children in the following age groups:
0 to 5: 6 to 10: Over 10 years of age:
4. Available to member’s children only? Yes No
5. Any field trips off premises? Yes No
If yes, please describe:
6. Does the club do a criminal background check on all counselors (employees, volunteers, and
contractors)? Yes No
7. Does the club’s employment process (employees, volunteers, contractors) include
verification of whether the individual has even been convicted of any crime, including sex-
related or child abuse offenses before an offer of employment is made? Yes No
8. How long do the day camps run: (Ex: first two weeks of August)
9. Daily hours: (Ex: 9 am to 2 pm Monday to Friday)
10. Does the club provide any transportation? Yes No
If yes, please describe:
DIRECTORS & OFFICERS / EMPLOYMENT PRACTICE LIABILITY
THIS SECTION IS AN APPLICATION FOR A CLAIMS MADE POLICY.
PLEASE READ YOUR POLICY CAREFULLY.
DIRECTORS & OFFICERS LIABILITY INFORMATION
1. Yes No Does the Applicant have a tax-exempt status under the U.S. Internal Revenue Code?
If no, provide an explanation:
2.
FINANCIAL INFORMATION CURRENT FISCAL YEAR PREVIOUS FISCAL YEAR
Total Assets: $ $
Net Assets / Fund Balance: $ $
Annual Revenue: $ $
Net Revenue: $ $
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06/2017
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3. 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
4. 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 No
Yes No
Yes No
Any disciplinary action by any regulatory agency or association?
Any administrative proceeding charging violation of a federal or state law or regulation?
Any other criminal actions? Yes No
5.
Yes No
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?
If yes, please attach details.
EMPLOYMENT PRACTICE LIABILITY INFORMATION:
1.
Total Part-Time:
Temporary:
Total Non U.S. based employees:
Please provide the following employee count information:
U.S. based employees:
Total Full-Time:
Volunteers:
Leased:
TOTAL SUM OF ABOVE:
2. 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:
3. Does the Applicant have an employment handbook that includes an “At Will” statement? Yes No
4. Does the Applicant use an employment application for every potential employee? Yes No
5. Does the Applicant use outside employment counsel for employment advice? Yes No
6. Does the Applicant have a full time, dedicated human resource staff? Yes No
7. 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 $ $ $
Golf and Country Club
Supplemental Application
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06/2017
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WARRANTY INFORMATION:
1.
With respect to this coverage, has any Underwriter refused, canceled or non-renewed
coverage? (Not Applicable in Missouri)
Yes
No
If yes, please provide details:
2.
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
3.
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.
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Supplemental Application
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WINTER WEATHER FREEZE-UP PROTECTION
1. Fire Protection and Testing
a. Is the building provided with an Automatic Fire Sprinkler System (AS)? Yes No N/A
i. If yes, approximately what percentage (%) of the building is sprinklered? %
ii. If yes, what type of sprinkler system is installed? Wet-Pipe Dry-Pipe Both
iii. If yes, when possible, is the sprinkler piping primarily run within conditioned
areas designed to ensure the temperature remains above the 45°F minimum
Yes No N/A
iv. If yes, is the testing & inspection by qualified sprinkler contractor completed
within past 12 months & includes a formal 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, ful
l insulation on piping or roof):
6.
General Comments:
Golf and Country Club
Supplemental Application
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06/2017
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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)
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Supplemental Application
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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 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)
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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
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).
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.
NAM
E (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
____________________________________________________
SIGNATURE DATE
SECT
ION TO BE COMPLETED BY THE P
RODUCER/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 - Golf - Country Clubs36-8544

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Completed 2 July 2020

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