Fillable Application - Performing Arts Facilities And Venues Supplemental36-11202 - Performing Arts Supplemental Application

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Application - Performing Arts Facilities And Venues Supplemental36-11202 - Performing Arts Supplemental Application

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PERFORMING ARTS FACILITIES AND VENUES
SUPPLEMENTAL APPLICATION
Pages 1-4 must be completed for all submissions
For Abuse and Molestation coverages, please complete page 4
If you provide security, please complete pages 5 - 6
For Liquor liability coverage, please complete pages 7 - 8
For Pyrotechnics exposure, please complete pages 9 - 11
For Hired and Non-Owned Auto coverage, please complete page 12
SUBMISSION REQUIREMENTS
1. Lease agreement between the insured and venue owner (if applicable)
2. Standard contract for the lease of the insured’s facilities to others
3. Contracts with and certificates of insurance from the subcontractors listed in Question #2 of the
General Liability section
4. Event schedule for the coming year
5. Inflatables / Amusement Devices Application if applicable.
6. Latest annual financial statement
7. Emergency evacuation Plan
8. Brochure, advertising materials and web site information
9. Currently valued insurance company loss runs for the current policy period plus three prior years
GENERAL INFORMATION
1. Applicant Name:
2. Mailing address:
Physical address:
3. Does the insured own or lease the facility? Own Lease
4. Contact person: Contact e-mail address:
Telephone: Web site address: www.
5. Business type: Corporation Partnership Individual
Non-Profit Governmental Entity Other:
6. Year business was established? Number of years under present management:
FEIN:
7. List all Named Insureds and their interests: Note: The First Named Insured requires common /
majority ownership of each Named Insured. If not, please explain.
a.
b.
c.
d.
e.
Explanation:
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and Venues Supplemental
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PROPERTY
1. Building construction: Frame Non-Combustible Modified fire resistive
Masonry Masonry Non-Combustible Fire resistive
2. Fire hydrant: feet Fire department: miles Volunteer Fire Department: Yes No
3. Roof construction:
List all property on the roof (HVAC, etc.):
4. Number of stories:
5. Year built:
If built prior to 1971, has it been inspected for lead paint and abated if
necessary?
Yes
No
If no, what is the plan for inspection and abatement? (if necessary)
6. Year of building updates: Roofing: Plumbing: Wiring: HVAC:
7. Any renovations planned? (describe)
8. Is your facility a historical landmark? Yes No
LIFE SAFETY
1. 100% sprinklered? Yes No
Any Omega sprinkler heads? Yes No
Date last serviced? Date of last sprinkler flow tests?
Number of currently tagged and operational fire extinguishers:
2. Central station fire alarm? Yes No
Central station burglar alarm? Yes No
Surveillance cameras? Yes No
3. Cooking facilities on premises? Yes No
If yes, automatic extinguishing system over deep fat fryers, grills & stoves? Yes No
How often are hood / ducts cleaned?
By whom? Insured Sub-contractor
If by sub
-contractor, how often are they serviced? Date la
st serv
iced
?
4.
Do you have
Automated External Defibrillator(s)(AED)? Yes
No
If yes, are sta
ff members trained to use it? Yes No
5. How many means of egress?
Are doors locked during performances? Yes No
Are all exits clearly marked? Yes No
Are all doors equipped with panic hardware? Yes No
6. Do you have backup emergency lighting and / or emergency generators in the
event of a power failure? Yes No
8. Please describe a typical performance:
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7. Do you have an eme
rgency evacuation plan? (If yes, attach a copy)
Yes No
Evacuation procedures and floor plans posted? Yes No
8. Are parking lots well lit? Yes No
Patrolled by security? Yes No
GENERAL LIABILITY
1. Annual number of attendees (all events): Total seating capacity:
Annual payroll: $ Number of employees:
Sales / Receipts:
a. Food / Restaurant: $
b. Liquor: $
c. Gift shop: $ Describe:
d. Parking: $
e. Other: $ Describe:
2. Please specify who has responsibility for the following event day operations:
Owner Insured Sub Other-N/A
a. Premises defects
b. Facility maintenance
c. Stage / Lighting
d. Food concessions
e. Liquor
f. Gift shop
g. Parking
h. Security
i. First aid
j. Fireworks / Pyrotechnics
k. Inflatables / Amusement devices
Explain all Other-N/A answers below:
3. Regarding contracts and certificates of insurance with sub-contractors and tenants.
Insured Sub/Tenant Mutual Neither
a. Is the Indemnification / Hold Harmless wording
in favor of?
b. Is the additional insured status in favor of?
c. Minimum insurance limits of $1,000,000?
d. Is a certificate of insurance required?
4. If temporary seating, what is the type?
Inspected prior to each performance? Yes No
5. Any self-promoted or co-promoted events? (if yes, provide a schedule) Yes No
6. Any performing arts camps? (if yes, attach a brochure) Yes No
Number of days the camp is open: Number of campers:
Are waivers with parental / guardian consent required? (If yes, attach a copy) Yes No
Day camp Overnight camp Age range:
Do you have any field trips? (If yes, attach a schedule) Yes No
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S
7. Are any other child care services provided? If yes, provide details:
Yes No
8.
Cov
erage limits requested:
Limit:
Each occurrence / Each claim $
General aggregate $
Products / Completed Operations aggregate $
Personal / Advertising Injury $
Damage to Premises Rented to You $
Liquor liability $
Stop Gap $
States:
Employee Benefits Liability $
Number of employees
Employed benefits administrator Yes No
Current carrier: Limit: $
Retroactive date:
Other: (specify) $
Other: (specify) $
Deductible:
$
Self-Insured Retention:$ Self-Funded Retention:$
ABUSE AND MOLESTATION
1. Does your current insurance program include Abuse and Molestation
coverage?
Yes
No
2. Does your employment process (for employees and volunteers) include verification of
whether the individual has
ever been convicted of any crime, includ
ing sex
related or child abuse related offenses, before an offer of employment is made?
Yes
No
3. Do you verify employment references for employees and volunteers? Yes No
4. Do you conduct personal interviews? Yes No
5. Are formal written procedures in place for hiring? (If yes, attach a copy) Yes No
6. Is there a written supervision plan that monitors staff in day-to-day
relationships with clients, both on and off premises? (If yes, attach a copy)
Yes
No
7. Do you have a written crisis plan for dealing with employees, volunteers,
victims, parents, authorities and the media if you have an incident of abuse?
Yes
No
(If yes, attach a copy)
8. Have any incidents resulted in an allegation of sexual abuse? Yes No
If yes, was the case settled? Yes No
Was the case taken to trial? Yes No
Amount paid for damages to the victim:$
Does your state allow criminal background checks? Yes No
If yes, do you run criminal background checks prior to hire for:
Employees? Yes No
Volunteers? Yes No
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SECURITY
(Complete only if security is the responsibility of the insured)
Part I:
1. Who is primarily responsible (via contract) for liability coverage for security personnel?
Insured? Yes No
Municipality? Yes No
Sub-contractor? Yes No
2. Employed or sub-contracted security personnel? Employed Sub-contracted
“Employed” is defined as individuals being paid and supervised directly by the insured. “Contract” is
defined as the existence of a written contract with another entity for security services that has
separate insurance coverage and provided a certificate naming the Insured as Additional Insured
with limits equal to or greater than the Insured.
3. Number and payroll of employed security personnel:
Unarmed: # Payroll: $
Armed (not including off duty police officers): # Payroll: $
Off duty police officers: # Payroll: $
4. Sub-contracted security – cost of sub-contract: $
5. Total maximum hours per day permitted at this and all other places of employment:
Total maximum hours per week:
6. What are the staffing guidelines per number of patrons?
Are the guidelines determined by:
Ordinance? Yes No
Statute? Yes No
Industry standard? Yes No
Other: (describe)
7. Is there a procedure to immediately report all incidents to the facility manager? Yes No
If yes, describe:
8. Does the supervisor make personal contact with each security person at least
once during each shift? If yes, describe:
Yes
No
9. Please explain all no answers:
10. Does the procedure include contacting previous employers over the previous
five (5) years?
Yes
No
11. Does the Applicant contact at least three (3) personal references? Yes No
12. Is c
ompletion of a minimum twenty (20) hours initial training program requi
red
before deployment? Yes No
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13 Who con
ducts the training and what are the traine
r’s qualifications:
14. Is a minimum of ten (10) hours on-site training required? Yes No
15. Is a minimum of four (4 ) hours of annual refresher or continuing education
training planned and conducted for each security employee? Yes No
16. Is each security person given a personal copy of the training / safety manual? Yes No
If yes, has each security person given management a written acknowledgment
of the policies and contents? Yes No
NOTE: PLEASE INCLUDE A COPY OF THE MANUAL AND A SAMPLE OF THE WRITTEN
ACKNOWLEDGEMENT
ARMED SECURITY EMPLOYEES:
1. Are the security personnel in uniform? Yes No
If yes, describe the uniform:
2. Are the security personnel identified by anything other than a uniform? Yes No
If yes, describe the identification and include an example or photograph.
3. Are psychological screen profiles used? Yes No
If yes, specify type:
4. Are criminal background checks completed? Yes No
If yes, what agency is utilized?
5. Please indicate any equipment carried or routinely available to security personnel:
Flashlight Type: Size: Construction:
Handcuffs First Aid Kit (including blood borne pathogen kit)
Nightstick Is night stick police regulation or other?
Taser / Phaser Chemicals (Mace, pepper gas)
Other:
Firearm – Caliber: .357 .38
.9mm Other:
Make: Colt S&W Ruger
Cover Holster - Type:
6. Is the ammunition: Standard Other:
7. Is firearm and ammunition approved and inspected by management or
security company? Yes No
8. Describe capabilities of each guard for constant communications with each
other, the supervisor, and management:
9. Are dogs used in your security operations? Yes No
If yes, provide the type of dogs(s), number, and describe duties.
Supplemental Application
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LIQUOR LIABILITY
1. Is the liquor license in Applicant’s name? Yes No
If no, what is the name on the license and their relationship to the insured: Yes No
Liquor license number:
Class of license:
2. Is the liquor service sub-contracted to a third party? Yes No
If yes, provide limits of liability maintained by the sub-contractor:
Is Applicant listed as Additional Insured under sub-contractors liquor liability
coverage? Yes No
Is Contingent Liquor liability coverage requested by Insured? Yes No
3. Has Applicant’s liquor license ever been revoked or suspended? If yes, explain: Yes No
4. Has applicant incurred claims for Liquor liability during the last three (3) years? Yes No
If yes, explain:
5. Has any insurer cancelled or non-renewed coverage during the last three (3)
years? If yes, explain:
Yes
No
6. Has Applicant ever been fined by Alcoholic Beverage Control or other
governmental regulator? If yes, explain: Yes No
7. Type of beverages sold:
Annual gross sales:
Liquor sales: $
Food sales: $
Other: (specify) $
8. Are patrons allowed to carry alcoholic beverages onto the premises? Yes No
If yes, what type?
9. Do you exercise the right to search and seizure contraband items? Yes No
If yes, how do you notify the public of this?
10. Do you maintain security personnel at entry check points? Yes No
If yes, what type?
11. Are the alcohol sales and consumption contained within one fixed site, or are
booths / stands located throughout the event site?
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12. Number of servers u
sed?
Are they professional servers?
Yes No
Explain:
Are they volunteer servers? Yes No
Explain:
13. Do the servers receive any type of alcohol awareness training? Yes No
If yes, explain:
14. Median age of liquor customers:
21-25 25-30 30-40 40 and over
15. Are minors allowed to enter the location where alcohol is being served? Yes No
If yes, how is underage consumption of alcohol prevented?
16. Explain how ID’s are checked:
17. Are uniformed police officers present at the site of alcohol sales? Yes No
Are undercover police officers present? Yes No
Are private security officers present? Yes No
Average number of officers present at site:
18. Are rules and regulations clearly displayed for patrons viewing? Yes No
Explain:
19. Is there a limit placed on the quantity of alcoholic beverages purchased
at one time? Yes No
Explain:
20. Is the parking area patrolled to prevent intoxicated drivers from leaving
the premises? Yes No
Explain:
21. Is there any type of designated driver program? Yes No
Explain:
22. Limit of liquor liability coverage requested: $
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PYROTECHNICS
(Complete if coverage is requested for Pyrotechnics Coverage (not including flashboxes))
1. Limit of liability requested: $1,000,000 Other:
2. Description of events:
3. Location of events:
4. Dates of events:
5. Who is the authority having jurisdiction over the use of pyrotechnics at your facility?
Local fire department State fire marshal Other: (please list)
What permit process must be followed prior to use of pyrotechnics at your facility?
6. Have you staged pyrotechnic displays before? Yes No
If yes, list any claims / losses that have occurred and the amount of loss:
Description
Date of Occurrence Amount of Loss
a)
b)
c)
7. Who will be the pyrotechnics operator? Named Insured Contractor
Complete this section if the Pyrotechnics Operator is the Named Insured.
a) List names of people shooting and describe their experience.
Please note: This coverage will exclude bodily injury liability to the fireworks shooter.
Name: Experience:
b) Where are the pyrotechnics stored when not in use?
Does it meet federal / state storage regulation? Yes No
What quantity of pyrotechnic material is stored on site? (number of shows, pounds etc.)
Describe the type of show and amount of pyrotechnics used in recurring
events:
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Describe
what fire prevention and suppression measures
are taken to support
the pyrotechnic loading and firing process:
Does the Applicant secure proper pyrotechnic permits for each event? Yes No
Are the shooters listed above licensed for pyrotechnics? Yes No
Complete this section if the Pyrotechnics Operator is a Contractor.
a) Name:
b) Is there an agreement with the contractor? Yes No
If yes, provide a copy of the agreement.
c) Will liability coverage be provided by the pyrotechnics contractor? Yes No
If yes, indicate limits of coverage provided:
$1,000,000 Greater than $1,000,000 Other:
Please attach a copy of certificate of insurance including any additional insured listing.
d) Do you confirm that the contractor has secured the proper pyrotechnic
permits for each event? Yes No
e) Describe what fire prevention and suppression measures are taken
to support the pyrotechnic loading and firing process:
f) Do you allow tenant users (including temporary tenant users) to conduct pyrotechnic
displays either themselves or through a contractor? Yes No
If yes, what steps are taken to ensure that the appropriate permits are
granted, appropriate fire safety codes are met, and that insurance has
been obtained from either the tenant or the tenant’s contractor which
lists the Applicant as an additional insured?
If no, does the tenant lease / use agreement indicate that pyrotechnic
displays are not permitted? Yes No
g) Are events with pyrotechnics held: Indoor Outdoor
h) What type of pyrotechnics will be displayed (as defined in NFPA code 1126)?
Aerial Shells Airbursts Black Powder Comets
Concussion effects Concussion mortars Saxon Flares
Flash Pots Flashpower Gerbs Integrals Mortars
Mines Mortars Rockets Electric matches
Wheels Salutes Waterfall, Falls, Park Curtains
Other, please list:
OUTDOOR PYROTECHNICS
(only complete if outdoor pyrotechnic displays are staged)
1. Are the events in compliance with NFPA 1123 or 1126? (Code for
fireworks display) Yes No
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2. Is there fenc
ing to keep spectators away from restricted areas during the
fireworks shooting? Yes No
If yes, distance of spectator fencing from launch site:
Distance of spectator parking area from launch site:
Distance of closest building or structure from launch site:
3. Will there be firefighting equipment on site during the event? Yes No
If no firefighting equipment on site, give distance to nearest fire station:
4. Will you have an ambulance on site? Yes No
If no, what is the estimated response time of an ambulance?
If no, what is the distance to nearest medical facility?
INDOOR PYROTECHNICS
(Only complete if indoor pyrotechnic displays are staged)
1. Are the events in compliance with NFPA 1126? (Standard code for the
use of pyrotechnics before a proximate audience)? Yes No
2. Is the facility sprinklered? Yes No
3. What other form of fire fighting equipment is available at the facility?
4. Does the facility have an emergency evacuation plan? Yes No
If yes, how often is the staff drilled on emergency evacuation?
5. Number of accessible (not locked) emergency exits at the facility:
6. What steps are taken to inform patrons of the locations of all emergency exits?
7. Maximum capacity of the facility:
8. Has the fire marshal approved the use of pyrotechnics at the facility? Yes No
If yes, as of what date:
HIRED & NON-OWNED AUTO
1. Does the Applicant have any owned automobiles? Yes No
NOTE: If Applicant has owned autos, the hired car and non-owned auto coverage should be placed
with the automobile carrier. Explain if an exception is requested.
2. Does the Applicant allow employees to use their own personal vehicles for
business purposes? Yes No
If yes, how many employees use their own personal vehicles?
If yes, how often? Daily Weekly Monthly Other:
3. Do you obtain Motor Vehicle Reports? Yes No
If yes, how often? Annually Every other year Other:
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4. Do you confirm that all employee
s who regularly u
se their cars for busine
ss
purposes carry minimum personal auto limits? Yes No
If yes, what minimum limits are required?
5. Please provide the approximate cost of hire for all hired or leased autos
during the course of the policy period: $
6. Limits of coverage required:
$100,000 $300,000 $500,000 $1,000,000 Other: $
7. Is hired auto physical damage required? Yes No
If yes, what is the maximum value of hired vehicle you would like insured? $
NOTE: Physical Damage deductibles provided $100 comprehensive / $1,000 collision.
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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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.
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 - Performing Arts Facilities And Venues Supplemental36-11202 - Performing Arts Supplemental Application

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Completed 2 July 2020

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