Fillable Application - Paintball Supplemental36-11495

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Application - Paintball Supplemental36-11495

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PAINTBALL SUPPLEMENTAL APPLICATION
SUBMISSION REQUIREMENTS
We must receive a copy of these documents with the Applicant’s application.
• Copy of the Applicant's Waiver, Release of Liability or Assumption or Risk form.
• Diagram of premises
• Copy of the rules of play
• Currently valued insurance company loss runs for the current policy period plus 3 prior years
BUSINESS INFORMATION
Proposed Effective Date:
1.
Business Name:
2.
Type of Business:
Individual
Limited Liability Company
Corporation
3.
Contact Name:
4.
E-mail Address:
5.
Business Phone:
Fax:
Cell:
6.
Mailing Address:
7.
Location Address: (If different from mailing address)
8.
FEIN:
Year Business Started:
9.
Detailed description of operations:
INSURANCE AND PROPERTY INFORMATION
1.
Current insurance carrier:
Exp. Date:
2.
Any incidents or claims whether reported or not in the last five (5) years?
Yes
No
If yes, please explain:
3.
Any policy declined, cancelled or non-renewed within the past three (3) years?
(Not Applicable in Missouri)
Yes
No
Paintball Supplemental Application
Page 1 of 7
© 2016 Philadelphia Consolidated Holding Corp.
12/2016
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4.
Does the Applicant own or lease the Applicant’s property?
Own
Lease
5.
Name of Lessor / Landlord:
Address of Lessor / Landlord:
6.
Name of other Additional Insured:
Address of other Additional Insured:
7.
Operations
Annual Gross Sales
Annual # of Participants
Paintball Games
(indoor and outdoor)
$
Retail Pro Shop Sales
(include offsite shops if applicable)
$
Equipment Rentals
$
Food and Drink
$
Other(specify):
$
Grand Totals
$
QUESTIONNAIRE
1.
Does the Applicant provide:
Airsoft
Archery Tag
Laser Tag
Nerf
Paintball
2.
Is the facility:
Indoor
Outdoor
Both
3.
Does the Applicant’s facility comply with PHLY’s Paintball Field Operator Safety
Guidelines shown at the end of this application?
Yes
No
4.
Years of paintball experience:
5.
Years of management experience:
6.
Is the facility enclosed or fenced?
Yes
No
7.
Does the Applicant have any inflatable, fabric or air supported structures such as, but
not limited to, bubbles or domes?
Yes
No
8.
Are waivers required for all participants? (Please attach a copy)
Yes
No
9.
Are there rules of play and are they posted? (Please attach a copy)
Yes
No
10.
Are goggles and safety masks, including ear protection, required at all times on the
playing fields?
Yes
No
11.
Are safety signs posted in all playing areas?
Yes
No
12.
a.
Describe all barriers and obstacles including their construction:
b.
Does the Applicant have any elevated structures?
Yes
No
If yes:
i.
What is the height?
ii.
Are there any ladders?
Yes
No
Paintball Supplemental Application
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© 2016 Philadelphia Consolidated Holding Corp.
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iii.
Are there any stairs or ramps?
Yes
No
If yes, are they built to code?
Yes
No
If yes, do they have walls to prevent participants from jumping down?
Yes
No
13.
How many referees are on the field during play?
a.
What is ratio of referees to players?
Referees: to Players:
14.
Are employees trained in first aid?
Yes
No
15.
Are customer’s equipment checked before use to make sure it meets minimum safety
requirements?
Yes
No
16.
Does the Applicant allow players or any other trained personnel to fill tanks?
Yes
No
17.
Does the Applicant allow the following:
First Strike Rounds
Paintball Grenades
Paintball Rocket Launchers
Simunitions
18.
How often is the Applicant’s equipment checked and velocity tested?
19.
Is there a required safety meeting before all games?
Yes
No
20.
Are barrel blocker devices required in all non-playing field areas?
Yes
No
21.
a. Is the paintball field in a wooded area?
Yes
No
b. Is the paintball field near any staging area, street or parking?
Yes
No
If yes, please describe:
22.
Does the Applicant use netting for all spectator areas? If yes:
Yes
No
a.
How many feet high is the netting?
b.
How many years old is the netting?
c.
If the Applicant has airsoft, does the Applicant keep players at least 60 feet away
from the netting?
Yes
No
23.
Has the Applicant tested the netting within the last three months to comply with the
ASTM standard of stopping paintballs when shot from 15 feet back into net, 10 shots
at 300 feet per second within a 4” circle?
Yes
No
Did it pass?
Yes
No
24.
Does the Applicant have boundary tape to keep spectators a minimum of 5” back
from netting?
Yes
No
25.
Are there any special events or tournaments held on the Applicant’s premises that the
Applicant runs?
Yes
No
26.
Are there any special events or tournaments held on the Applicant’s premises that are
run by others?
Yes
No
27.
Are Certificates of Insurance obtained from those independent entities naming the
Applicant as additional insured?
Yes
No
28.
Is there any overnight camping?
Yes
No
29.
Are there any night games?
Yes
No
Paintball Supplemental Application
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© 2016 Philadelphia Consolidated Holding Corp.
12/2016
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30.
Are there any hayrides, zombie paintball or haunted attractions?
Yes
No
If yes, please describe:
31.
Are there other events or activities other than those listed above?
Yes
No
If yes, please list activities:
PAINTBALL FIELD OPERATOR SAFETY GUIDELINES
1.
Field Operations
Strict control must be exercised over all areas including:
a.
Field Entrance
c.
Parking areas
e.
Playing Fields
b.
Sales and Services
d.
Spectator areas
f.
Staging Areas
2.
Personnel
All field staff must be fully and properly trained. Referees and fill station attendants
must be sixteen (16) years of age or older.
3.
Emergency Procedures
All field staff must be t rained to properly respond in the event of an ac cident or
emergency and instructed to respond immediately. Field Staff must know the exact
location of the field telephone, readily accessible first aid kit and incident report forms.
Management must fill out and return an incident form immediately following all
injuries.
4.
Field Orientation
Prior to the first game, each player must undergo a formal orientation session
including:
a.
Detailed explanation of the player safety rules – clearly specifying those rules
which result in player ejection.
b.
Game rules
c.
The geographical diagram of the field
d.
Emergency procedures
e.
Referees are assigned to each group at this time.
5.
Barrel Blocking Device Regulation
The mandatory use of industry-approved barrel blocking devices (BBD) must be
strictly enforced at all times in all non-playing areas of the field. Barrel plugs are no
longer considered adequate protection due to differing barrel sizes and increased
rates of fire. Operations must remain fully stocked to provide BBD’s for all rental
equipment and a lso for customers to buy if necessary. ( Towels, socks, or stick
squeegees are not considered BBD’s).
6.
Safety goggles
Mandatory goggle enforcement is required in all areas where “goggles on” signs are
posted. I ndustry-approved full-face mask goggle systems must meet or exceed
ASTM Guidelines which require:
a.
Full enclosure of the eye cavity using 06 Lexan lenses secured within frames
and to the head with a headband.
Paintball Supplemental Application
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b.
The face and ear protector components must be attached securely to the goggle
frame to present full coverage (no gaps) to the bottom of the chin, along the
jawbone, temples and ears.
c.
Modifications are prohibited.
d.
Wash, disinfect, and inspect goggles regularly.
7.
Trigger Guards
Trigger guards are mandatory on all paintball markers used by participants at the
Applicant’s facility. The trigger guard must be rigid, wider than the trigger area, and
enclose the trigger area.
8.
Safety Netting
Netting (12” required, 20” recommended) must be installed around all play areas and
must be m aintained and checked regularly. Approved netting and / or 300 feet of
open space must surround all areas of play. Carrier requires each operator to test the
netting per ASTM Guidelines.
●
Stand 15’ from netting and shoot 10 shots at a 4” circle at 300 fps. No part of the
paintball shell may pass through larger than 3 by 5 mm rectangle.
●
Bunkers must be a minimum of 20’ from the netting and spectators must be kept
5’ away from the netting at all times.
9.
Chronographing Procedures
Maintain at least one (1) chronograph (preferably two) with a back-up battery at the
field at all times. All paintball markers must be chronographed before players enter
the field and before each new set of games. A chronograph referee must be available
at all times to strictly enforce velocity guidelines. Velocities must be adjusted so that
three (3) consecutive shots through the chronograph do not exceed:
Paintball
●
300 (FPS) outdoor games
●
250 – 275 (FPS) indoor games
●
Airsoft: 400 (FPS) outdoor games (20BBs)
●
300 (FPS) indoor games and close quarter (20BBs)
●
350 (FPS) outdoor games (25BBs)
●
300 (FPS) indoor and close quarter (25BBs)
●
Snipers maximum velocity: 500 FPS and no shots closer than 100 feet to
opponent. Sniper weapons must not have the ability to fire FULL AUTO.
Underwriting approval is required for Sniper velocities that exceed 400 FPS
10.
Field Maintenance
Boundaries of all outdoor playing fields must be clearly and continuously marked with
rope, tape or other highly visible material. The field must be inspected frequently for
natural or man-made hazards. Paintball markers must be cleaned and inspected
weekly. A designated staff member must inspect the chronograph, first aid kit, mobile
telephone, scale, fill station, CO2 cylinders, and all field equipment (including safety
signs) daily.
11.
Player Safety Rules
Each player / participant must read the player safety rules prior to signing the waiver
of liability. The player safety rules must be posted at the field entrance and counter /
sales office. Mandatory ejection (without warning!) of any player that knowingly
violates the required safety rules is required – especially mask violation!
Paintball Supplemental Application
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© 2016 Philadelphia Consolidated Holding Corp.
12/2016
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12.
Paintball Markers
Automatic markers that are in a mode of self-loading and s hooting at a r ate faster
than one round per manual activation of the trigger’s cycle are allowed by
UNDERWRITER APPROVAL ONLY. An additional premium may apply for coverage
for activities involving ramping / multiple round burst modes. A semi-automatic
marker does qualify for the program without approval if it is gravity fed or tractor fed at
a rate of no more than fifteen (15) balls per second. In addition, off-premise marker
rental is prohibited in this program.
13.
Safety Signs
●
“Goggles on” signs must be posted at every entrance to active play areas.
●
“Barrel Blocking Device” signs must be posted at every exit of active play areas.
●
“Caution! Paintball Game Area” signs must be posted at any location where the
operators / field manager might expect unauthorized direct access to the active
playing field.
14.
Filling Stations
Only trained personnel are allowed to perform tank fills. Allowing players to fill their
own tanks is prohibited. O nly exception might be employed-supervised multi-fill air
stations where tanks have already been checked that day. C O2 cylinders must be
chained in an upright position. An on-site scale is required to prevent over-fill.
Paintball Supplemental Application
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© 2016 Philadelphia Consolidated Holding Corp.
12/2016
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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 F ALSE 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 ST ATEMENT 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
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)
Paintball Supplemental Application
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© 2016 Philadelphia Consolidated Holding Corp.
12/2016
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