Fillable Application - Museums And Cultural Institutions Supplemental36-9571

Fill Online, Printable, Fillable, Blank Application - Museums And Cultural Institutions Supplemental36-9571 Form

Use Fill to complete blank online PHILADELPHIA INSURANCE COMPANIES pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Application - Museums And Cultural Institutions Supplemental36-9571

On average this form takes 140 minutes to complete

The Application - Museums And Cultural Institutions Supplemental36-9571 form is 18 pages long and contains:

  • 0 signatures
  • 25 check-boxes
  • 547 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Philadelphia Insurance Companies forms online.

BROWSE PHILADELPHIA INSURANCE COMPANIES FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
MUSEUMS & CULTURAL INSTITUTIONS SUPPLEMENT
SUBMISSION REQUIREMENTS
Please include the following with the submission:
• ACORD Application (for all lines of coverage to be written)
• Loss Runs (current year plus 3 years)
• Statement of Values (for blanket and/ or agreed value)
• Latest Annual Financial Statement
• Recent Appraisal for Historic Buildings and/ or Collections
• Schedule of Collections
Applicant Name:
Street Address:
City:
State:
Website Address:
Billing Contact Information:
Risk Management/ Inspection Contact:
Risk Management E-Mail:
Phone:
SECTION I – GENERAL INFORMATION
1.
Type of museum:
2.
Full description of operations:
3.
Is the Museum a member of the Alliance of Museums (AAM)?
Yes
No
4.
Average number of visitors annually:
5.
Professional organization memberships:
6.
Is the Applicant accredited?
Yes
No
If yes, by whom:
7.
List hours of operations:
8.
Does the Applicant have a formal safety program in place?
Yes
No
9.
Does the Applicant have a written emergency evacuation plan in place?
Yes
No
SECTION II - PROPERTY
In addition to completing the ACORD application,
please answer the below questions regarding specific exposures.
1.
Is this an historic building or is the building over 50 years old?
Yes
No
If yes to either, please provide the following information:
Provide detailed information regarding any renovations or updates to the building,
including dates of completion.
2.
Electrical Updates
a.
Type of Wiring:
BX Cable
Romex
Aluminum
Conduit
Circuit Breakers
Fuses
Both
b.
Has any re-wiring been done since the original construction?
Yes
No
If yes, date completed:
c.
Any Knob and Tube wiring present?
Yes
No
d.
If the property has Aluminum wiring, has it been retrofitted by a licensed electrician?
Yes
No
If yes, date updated:
Museums & Cultural Institutions Supplement
Page 1 of 12
© 2018 Philadelphia Consolidated Holding Corp.
10/2018
Clear Application
Print Application
3.
Heating & Cooling
a.
What type of heating/ cooling system is used in the building?
b.
Primary:
Wall Furnace
Electric
Gas Heater
Floor Furnace
Forced Air
Wood Stove
c.
What type of fuel is used?
d.
Secondary:
Wood Stove
Gas Heater
Electric Space Heater
Other:
e.
Has the entire original heating/ cooling system or furnace been replaced?
Yes
No
If yes, date completed:
4.
Plumbing
a.
Pipes are:
Copper
Galvanized
Plastic
Other:
b.
Age of hot water system:
c.
Has any re-plumbing been done since the original construction?
Yes
No
If yes, to what extent:
If yes, date completed:
5.
Roofing
a.
Type of Roof:
Tile
Composition
Wood/ Shake
Comp Shingle
Other:
b.
Age of roof:
c.
Has the entire roof been replaced?
Yes
No
If yes, date completed:
6.
If built prior to 1980, has an asbestos and lead survey been conducted?
Yes
No
a.
If yes, date completed:
b.
Has the asbestos or lead been removed?
Yes
No
7.
Historic Buildings
Loc & Bldg
Loc & Bldg Loc & Bldg
Is this building listed on the National
Historic Register?
Are replacement building materials
available locally?
Will local ordinances allow the building to
be rebuilt at the same location?
Has the building been completely restored?
If not, what percentage of the building has
been restored?
What is the anticipated completion date for
the restoration?
Is the building currently under
construction?
If yes, what percentage of the building is
under construction?
Is the building ADA compliant?
Is the building also a private home, hotel or
inn?
If someone lives on the premises full time,
do they have a separate homeowner’s
insurance policy?
Museums & Cultural Institutions Supplement
Page 2 of 12
© 2018 Philadelphia Consolidated Holding Corp.
10/2018
Clear Application
Print Application
SECTION III - COLLECTIONS
Location #1
Location #2
Location #3
OWNED COLLECTIONS
Limit of Insurance
$
$
$
Deductible
$
$
$
Total Values
$
$
$
Average Value Per Item
$
$
$
Maximum Value Per Item
(Values based off of fair market value)
$
$
$
LOAN COLLECTIONS
Limit of Insurance
$
$
$
Deductible
$
$
$
Total Values
$
$
$
Average Value Per Item
$
$
$
Maximum Value Per Item
(Values as stated on loan agreement)
$
$
$
TOTAL LIMIT OF INSURANCE
(Owned + Loan) =
$
$
$
1.
Does the Applicant have a curator on staff?
Yes
No
2.
Does the Applicant repair, restore, retouch or conserve collection/ fine arts?
Yes
No
If yes, please describe:
3.
What is the percentage of the operations: %
4.
Owned collection
a.
Is the Applicant’s permanent collections fully inventoried?
Yes
No
b.
Are all records and documents stored electronically and an electronic copy stored off
site?
Yes
No
c.
Date values were last updated:
d.
Percent of owned collection:
Fragile: %
Non-Fragile: %
e.
Any precious metal/ gems part of the collection?
Yes
No
5.
Are there temperature and humidity controls in the exhibition galleries and storage areas?
Yes
No
a.
If temperature and humidity controlled, does the Applicant have back-up generators?
Yes
No
If yes, where are they located: (check all that apply)
Basement
Ground Floor
Roof
Elevated Off Ground
6.
Are all collectibles, fine arts, rare books, manuscripts, etc. catalogued, photographed or
video taped?
Yes
No
7.
Are all important records & documents kept in fire-resistant safes with duplicates kept
off-premises?
Yes
No
8.
Are all film collections on cellulose nitrate film stored in fire resistive vaults?
Yes
No
9.
Is there any below-grade/ basement exposure?
Yes
No
If yes, how much value is located below grade: $
10.
If below-grade/ basement exposure, how are items stored?
11.
Are items stored at least 12 inches off the ground?
Yes
No
12.
What is the maximum value per item located below-grade: $
13.
Does the Applicant have a written emergency response plan?
Yes
No
14.
Loaned Collections
a.
Are written loan agreements obtained for all collections loaned to the Applicant?
Yes
No
b.
Do the agreements specify who is responsible for damage and insurance?
Yes
No
c.
Is valuation agreed upon for a total loss?
Yes
No
Partial Loss?
Yes
No
d.
Is the condition of each collection documented upon receipt?
Yes
No
e.
Does the Applicant make a photographic record of objects within all temporary
collection?
Yes
No
f.
Percent of collection on loan:
Fragile: %
Non-Fragile: %
15.
Percent of current collection is:
Owned: %
On Loan: %
Museums & Cultural Institutions Supplement
Page 3 of 12
© 2018 Philadelphia Consolidated Holding Corp.
10/2018
Clear Application
Print Application
16.
Collection on loan from others
a.
Who is responsible for the insurance while property is in transit:
b.
Who is responsible for the insurance while at the insured’s premises:
c.
Are the packers trained in proper packing methods for valuable items?
Yes
No
17.
Collections loaned to others
a.
Who is responsible for the insurance while property is in transit:
b.
Who is responsible for the insurance while at the loaned premises:
c.
Are the packers trained in proper packing methods for valuable items?
Yes
No
SECTION IV – TRANSIT EXPOSURE
1.
Limit of Insurance: $
Deductible: $
2.
Type of shipping
Owned vehicles:
%
Air:
%
Carriers:
%
Registered Mail:
%
International Shipment:
%
3.
Does the Applicant ship internationally via ocean cargo?
Yes
No
4.
Name of carriers:
5.
Do the carriers specialize in shipping and packing of art works?
Yes
No
6.
What percentage of the value of the items is declared to carriers for hire: %
7.
Any overnight stay?
Yes
No
8.
Who is responsible for packing and unpacking:
9.
Are collections shipped outside the U.S.?
Yes
No
10.
Is there documentation of values agreement between the museum and the borrower?
Yes
No
11.
Are there condition reports on all incoming and outgoing shipments?
Yes
No
SECTION V - SECURITY
1.
Does the Applicant have a formal written protection plan?
Yes
No
Are all of the staff aware of the procedures?
Yes
No
2.
Does the Applicant have security guards?
Yes
No
If yes, are they:
Museum Staff
or
Hired Contractors
3.
Are the guards armed?
Yes
No
If yes:
Number of armed guards:
Number of Unarmed guards:
4.
What percentage of the guards roam throughout the museum?
%
What percentage of the guards are stationary?
%
5.
Is there a central station alarm (both fire and burglar)
Yes
No
If yes, what is the name of the monitoring company?
6.
Does the central station alarm have line security?
Yes
No
7.
Are there security cameras?
Yes
No
If yes, monitored 24/7?
Yes
No
How many hours does the Applicant save the camera recordings:
8.
Are exterior doors and windows equipped with sensors, break detecting and motion
devices?
Yes
No
9.
Is there an intrusion detection system?
Yes
No
10.
Is there a motion detection system throughout the museum?
Yes
No
11.
Are high value paintings individually alarmed?
Yes
No
12.
Are systems capable of operating during a power failure?
Yes
No
SECTION VI – GENERAL LIABILITY
1.
Is the staff required to report all incidences to management that may result in a claim?
Yes
No
2.
Are written records of all incidences kept by management?
Yes
No
3.
Are all incidences reviewed?
Yes
No
4.
Does the Applicant have volunteer workers?
Yes
No
a.
What is the average number of volunteers daily?
b.
Describe their duties:
Museums & Cultural Institutions Supplement
Page 4 of 12
© 2018 Philadelphia Consolidated Holding Corp.
10/2018
Clear Application
Print Application
5.
Please indicate if the Applicant has any of the following exposures:
a.
Theater?
Yes
No
Type:
Number of annual admissions:
b.
Aquarium?
Yes
No
Dimensions:
Types of fish:
c.
Children’s camp?
Yes
No
Dates of operations:
Number of children attending annually:
d.
Concerts?
Yes
No
Type(s):
Number annually:
Frequency:
e.
Lectures:
Yes
No
Type(s):
Number annually:
Frequency:
f.
Reflecting pool, wishing wells, lakes, fountains, ponds?
Yes
No
Type(s):
Are signs posted warning visitors not to enter or touch the water?
Yes
No
g.
Animals?
Yes
No
Type(s):
Can the animals be handled by visitors?
Yes
No
6.
Are all hands-on exhibits inspected daily to check for broken pieces or malfunctions?
Yes
No
7.
Are there guided tours of the museum?
Always
Special groups only
8.
Do school groups require chaperones to stay with the children at all times?
Yes
No
If no, please describe supervision:
9.
Does the Applicant have a gift shop?
Yes
No
a.
Annual gross receipts: $
b.
Describe the items that are sold:
c.
Is the shop operated by an independent contractor?
Yes
No
d.
Are hold harmless agreements and certificates of insurance obtained from the
contractor and all suppliers or licensees?
Yes
No
10.
Does the Applicant have a restaurant or cafeteria?
Yes
No
a.
Annual gross receipts: $
SECTION VII – SPECIAL EVENTS
1.
Does the Applicant rent the premises to others for events such as wedding and parties?
Yes
No
a.
Type(s)
Number of events annually:
b.
Is a member of the museum’s staff present at all times?
Yes
No
2.
Is liquor served?
Yes
No
a.
Is catering by an outside company provided to serve the liquor?
Yes
No
b.
Are they trained in TIPS?
Yes
No
c.
Are hold harmless agreements and certificates of insurance obtained from all
lessees and suppliers?
Yes
No
3.
Are any special events for fundraising or education purposes organized, promoted or
sponsored by the Applicant?
Yes
No
a.
Please list the dates and types of events held:
b.
Are they on the Applicant’s premises?
Yes
No
c.
Are hold harmless agreements and certificates of insurance obtained from other
sponsors, promoters or organizers?
Yes
No
4.
Does the Applicant plan any special exhibitions or events that would generate an
unusually large number of visitors?
Yes
No
If yes, please describe:
Museums & Cultural Institutions Supplement
Page 5 of 12
© 2018 Philadelphia Consolidated Holding Corp.
10/2018
Clear Application
Print Application
SECTION VIII – ABUSE AND MOLESTATION
1.
Does the Applicant’s employment process 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
2.
Does the Applicant’s state permit the Applicant to do criminal background investigations?
Yes
No
If yes, does the Applicant routinely request and receive such background investigations?
Yes
No
3.
Does the Applicant verify employment related references?
Yes
No
4.
Does the Applicant conduct a personal interview?
Yes
No
5.
Does the Applicant have written procedures for dealing with sexual abuse?
Yes
No
If yes, please attach a copy.
6.
Has the Applicant’s organization ever had an incident which resulted in an allegation of
sexual abuse? If yes, please explain below.
Yes
No
a.
Was a claim made against the organization?
Yes
No
b.
Was the case settled?
Yes
No
c.
Was the case taken to trial?
Yes
No
d.
How much money was paid as damages to the victim?
8.
Regarding coverage for abuse & molestation, does the Applicant’s current insurance
program:
Exclude Coverage
Limit Coverage (please indicate limit of liability) $
Neither exclude nor limit coverage
Please write all comments regarding above answers below:
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.
Does the Applicant have a tax-exempt status under the U.S. Internal Revenue Code?
Yes
No
If no, provide an explanation:
2.
FINANCIAL INFORMATION
CURRENT FISCAL YEAR
PREVIOUS FISCAL YEAR
Total Assets:
$
$
Net Assets / Fund Balance:
$
$
Annual Revenue:
$
$
Net Revenue:
$
$
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
Museums & Cultural Institutions Supplement
Page 6 of 12
© 2018 Philadelphia Consolidated Holding Corp.
10/2018
Clear Application
Print Application
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
Any disciplinary action by any regulatory agency or association?
Yes
No
Any administrative proceeding charging violation of a federal or state law or regulation?
Yes
No
Any other criminal actions?
Yes
No
5.
In the past 24 or next 12 months has the Applicant been, or anticipate being involved in
any merger, acquisitions or consolidation with another entity?
Yes
No
If yes, please attach details.
EMPLOYMENT PRACTICE LIABILITY INFORMATION
1.
Please provide the following employee count information:
U.S. based employees:
Total Full-Time:
Total Part-Time:
Volunteers:
Temporary:
Leased:
Total Non U.S. based employees:
TOTAL SUM OF ABOVE:
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
$
$
$
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
Museums & Cultural Institutions Supplement
Page 7 of 12
© 2018 Philadelphia Consolidated Holding Corp.
10/2018
Clear Application
Print Application
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 cov
erage 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.
Museums & Cultural Institutions Supplement
Page 8 of 12
© 2018 Philadelphia Consolidated Holding Corp.
10/2018
Clear Application
Print Application
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 winterizatio
n 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
moni
toring, heat trace, full insulation on piping or roof):
6.
General Comments:
Museums & Cultural Institutions Supplement
Page 9 of 12
© 2018 Philadelphia Consolidated Holding Corp.
10/2018
Print Application
Clear Application
Clear Application
Print Application
Clear Application
Print Application
FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her
knowledge and belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments
submitted with this Application) are true and complete and may be relied upon by Company * in quoting and issuing the
policy. If any of the information in this Application changes prior to the effective date of the policy, the Applicant will notify
the Company of such changes and the Company may modify or withdraw the quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance
Company
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN
APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SUBJECTS THAT PERSON TO CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY
CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW
YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS ($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, RI, TN, VA, VT, WA AND WV).
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 (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
PRODUCE
R 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)
Museums & Cultural Institutions Supplement
Page 10 of 12
© 2018 Philadelphia Consolidated Holding Corp.
10/2018
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 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
Clear Application
Print Application
Clear Application
Print Application
FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief
and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true
and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes
prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the
quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,
MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN
EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, PA, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE
IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO
KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE
OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM
INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY
AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER
FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A
FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER
OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR
PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR
COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT
MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT,
FINES OR A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN PENNSYLVANIA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
__________
___________________________________________________
SIGNATURE DATE
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)
PI-CYBE-APP (11/16)
Page 2 of 2
Clear Application
Print Application
Clear Application
Print Application
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Application - Museums And Cultural Institutions Supplemental36-9571

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 2 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document