Fillable Application - Homeowners Association %28PUD%29 Supplement - FULL Amenities36-10557

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Application - Homeowners Association %28PUD%29 Supplement - FULL Amenities36-10557

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HOMEOWNERS ASSOCIATION (PUD) PROGRAM SUPPLEMENTAL
APPLICATION - FULL AMENITIES
Name of Association:
Location address (required):
City: State: Zip:
Website Address: www.
Type of Association: (Civic Associations are NOT eligible)
Townhouse Cluster Home Single Home Master Other (specify):
Association Membership: Mandatory Voluntary
SUBMISSION REQUIREMENTS
• Completed & SIGNED Supplemental Application • Plot Plan
• Financials including budget • Copy of D & O declaration page (for umbrella)
• Carrier generated currently – valued loss runs (current year + last three years)
SECTION I – GENERAL INFORMATION
1. Management Company Name:
Address:
City: State: Zip:
2. Billing Contact Name:
Phone Number: Email Address:
3. Risk Management Contact:
Phone Number: Email Address:
4. Number of Units Developed:
5. Projected Total number of units:
6. Year property was built:
7. Date of completion:
8. Is developer involved on the Association’s board? Yes No
SECTION II – PREVIOUS CARRIER INFORMATION
Carrier Expiration Annual Premium
Package Policy:
$
D & O:
$
Fidelity (Crime):
$
SECTION III – COVERAGE SELECTION
A - Property Coverage Part
Clubhouse
1. Year Built: Square Footage:
Last Roof Update:
Automatic Sprinklers? Yes No
Percentage Sprinklered: %
If applicable, are sprinkler pipes running through attic area insulated? N/A Yes No
2. Central Station Alarm? Yes No
How are they monitored?
3. Number of stories:
4. Are there hydrants on the property? Yes No
5. Property Deductible: $1,000 $2,500 $5,000 Other:
6. Coinsured Options: 80% 90% 100%
7. Equipment breakdown coverage required? Yes No
HOA (PUD) Program Supplemental Application
Page 1 of 7
© 2018 Philadelphia Consolidated Holding Corp.
07/2018
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B - General Liability Coverage Part
Limits of Liability:
$1,000,000 / $2,000,000
$2,000,000 / $4,000,000
C - Automobile Coverage Part
1.
Hired and Non-Owned Coverage?
Yes
No
(If there are vehicles, please attach the ACORD form inclusive of the schedule of vehicles and drivers)
D - Crime Coverage Part
1.
Blanket Employee Dishonesty:
Limit: $
Deductible: $
2.
Loss of Monies & Securities:
On / Off premises: $
Deductible: $
3.
Number of officers and employees who have custody of money:
4.
By whom is the financial audit completed?
CPA
Public Accountant
Staff
Other:
5.
Frequency of audits:
Quarterly
Semi-Annually
Annually
6.
Is there a countersignature procedure in place?
Yes
No
7.
Are the bank accounts reconciled by an individual other than someone who is authorized to
make deposit or withdrawals?
Yes
No
E - Umbrella Coverage Part
1.
Limit of Liability: $
2.
Underlying Insurance
Limit
Carrier
Effective Date
Auto Liability:
$
Employers Liability:
$
D & O:
$
SECTION IV – EXPOSURES
Description of Exposure
Construction
Quantity
Value
Business Personal Property
Clubhouse
$
Cabana
$
Docks / Slips
$
Fitness Center
(Property Limit applies if separate from clubhouse)
$
Lakes (acres)
$
Playground (each)
$
Pools/Spa/Jacuzzi (each)
$
Tennis Courts / Basketball / Sports Courts (each)
$
Streets
Golf Courses (each)
$
Gates / Walls / Fences
$
Guardhouse
$
Irrigation System
(underground sprinkler system)
$
Signs
$
Trees/Shrubs
$
Dog Park
$
Miscellaneous (please describe):
$
Total Property limits:
$
1.
Playgrounds (if applicable), what pieces of equipment are there (specify):
Mulch
Rubber
Sand
Grass
Concrete / Asphalt
2.
Is it the financial responsibility of the Association to maintain the roads?
Yes
No
3.
Is there a fitness center?
Yes
No
a.
What is the square footage?
$
HOA (PUD) Program Supplemental Application
Page 2 of 7
© 2018 Philadelphia Consolidated Holding Corp.
07/2018
$
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b.
If yes, are there signed Release or Waiver of Liability forms required?
Yes
No
c.
If yes, are medical or clinical services provided?
Yes
No
d.
Are there fitness trainers?
Yes
No
4.
Is there a swimming pool?
Yes
No
If yes:
a.
Number of pools:
b.
Are all swimming pools and spas compliant with Virginia Graeme Baker Pool and Spa
Safety Act?
Yes
No
c.
Lifeguard on duty?
Yes
No
d.
Fenced with a self-locking gate?
Yes
No
e.
Clear depth markers?
Yes
No
f.
Visible life safety equipment?
Yes
No
g.
A sign posted with rules?
Yes
No
h.
Diving board over 1 meter?
Yes
No
i.
Water Slides?
Yes
No
If yes:
1)
Describe the water slide and any additional features:
2)
The height of the water slide:
3)
The slope of the water slide:
4)
The length of the water slide:
5)
Is the step tower area enclosed?
Yes
No
6)
The depth of the water where the slide rider drops into the water:
7)
Provide a picture of the slide.
8)
The name of the company that constructed the slide:
9)
Is the maintenance conducted by an outside professional with proof of liability
insurance?
Yes
No
10)
What is the inspection schedule:
11)
Maximum number of persons allowed on the water slide at one time:
12)
The ratio of swimmers to lifeguards: to
13)
Are lifeguards trained in the operations and rules of the water slide usage?
Yes
No
14)
How is the water slide secured so that no unauthorized use occurs?
15)
Does the Applicant post the rules on use of the water slide for all to review?
Yes
No
16)
Does the Applicant keep a log of daily inspection of the water slide?
Yes
No
17)
How is the water slide kept restricted when not in use?
j.
Does the Association sponsor a swim team?
Yes
No
k.
Are sports competitions or meets held on premises?
Yes
No
5.
Is there an Association owned lake?
Yes
No
If yes:
a.
Lake size (in area / acres):
Lake Depth:
b.
Lake Use:
Canoes
Paddle Boats
Jet Skis
Sailboats
Water Skiing
Fishing
Power Boats
Row Boats
Swimming
Floating Bounce
Platforms
c.
Is there a lifeguard on duty?
Yes
No
d.
Are there gasoline or diesel powered boats on the lake?
Yes
No
If yes, please advise the following information:
1).
What is the maximum horsepower on the lake:
2)
What is the maximum boat length allowed on the lake:
e.
Is there a dam?
Yes
No
If yes, please advise the following information:
1)
Depth:
Acreage:
Height:
HOA (PUD) Program Supplemental Application
Page 3 of 7
© 2018 Philadelphia Consolidated Holding Corp.
07/2018
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2)
How frequently is the dam inspected:
3)
Hazard classification:
4)
Attach latest dam inspection.
f.
Are signs posted?
6.
Is there a beach?
Yes
No
If yes:
a.
Lake or Coastal
b.
Is there a lifeguard on duty?
Yes
No
c.
Are signs posted?
Yes
No
d.
Is swimming area roped off?
Yes
No
7.
Do any of the following exposures exist?
Airport
Boat Rental
Sewage Treatment Facility
Animal Stables
Bounce Houses or Trampolines
Skate Park
Bridges
Ice Skating
Water Treatment Facility
8.
Brush Exposure:
Thick
Moderate
Barren
9.
Confirm Certificates of Insurance are received for all outside contractors?
Yes
No
10.
Liability insurance is verified for:
Landscaping
Maintenance
Pool Service
Plumbing
11.
Is there a guard service provided?
Yes
No
If yes, please answer the below:
a.
Type of guard service provided:
24 hour
Evenings
Other:
b.
Are the guards:
Armed
Unarmed
c.
Are the guards:
Employees
Off Duty Police
Independent Contractors *
Non-cash
compensated security
*If security service is an independent contractor, please provide a Certificate of Insurance and a fully executed
copy of the contract.
12.
Are the premises monitored by a closed circuit TV?
Yes
No
13.
Is this a gated community or gated property?
Yes
No
If yes, please describe access:
14.
Describe any fixed security measures in place. (i.e. window security in place, cards, locks,
sliding glass doors, etc.).
15.
Are incident reports provided to senior management of the property management company for
security improvement action plans to be implemented?
Yes
No
16.
What process is followed after a violent incident takes place?
17.
Are criminal background checks conducted on all employees?
Yes
No
18.
Any property leased to others?
Yes
No
19.
Does the association sponsor any sport teams or events?
Yes
No
If yes, please describe:
HOA (PUD) Program Supplemental Application
Page 4 of 7
© 2018 Philadelphia Consolidated Holding Corp.
07/2018
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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
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)
HOA (PUD) Program Supplemental Application
Page 5 of 7
© 2018 Philadelphia Consolidated Holding Corp.
07/2018
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.
CYBER SECURITY LIABILITY ENDORSEMENT – SUPPLEMENTAL
QUESTIONNAIRE
Name of Applicant:
Address of Applicant:
City: State: Zip:
Website: www:
Nature of Operations:
1. Annual sales or revenue: $
2. Does the Applicant collect, store or otherwise handle any Personally Identifiable Information (PII)
belonging to customers, clients, or other third parties, other than employees?
If yes, please indicate the types of Personally Identifiable Information held (check all that apply):
Yes No
a. Social Security Numbers, Bank or Other Financial Account Details, Driver’s License or
other State Identification Numbers
b. Non-public Medical or Healthcare Data, including Protected Health Information (PHI)
c. Credit or Debit Card Information
3. a. During the last three (3) years, has anyone alleged that the Applicant was responsible for
damage to their computer system(s) arising out of the operation of the Applicant’s computer
system(s)?
Yes No
b. During the last three (3) years, has anyone made a demand, claim, complaint, or filed a
lawsuit against
the Applicant alleg
ing 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
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,
MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN
EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, PA, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE
IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO
KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE
OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM
INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY
AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER
FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A
FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER
OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR
PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR
COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT
MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT,
FINES OR A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN PENNSYLVANIA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
_______
______________________________________________________
SIGNATURE DATE
SEC
TION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
PI-CYBE-APP (11/16)
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Application - Homeowners Association %28PUD%29 Supplement - FULL Amenities36-10557

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