Fillable Application - Residential36-9178

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Application - Residential36-9178

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RESIDENTIAL APPLICATION
Name Insured:
C/O (if applicable):
Effective Date: Website Address:
SUBMISSION REQUIREMENTS
• Color Photos (representative buildings and auxiliary buildings)
• 4 year currently valued company loss runs (5 year currently valued company loss runs for accounts over
$100,000)
• Plot Plan
• Statement of Values (include auxiliary buildings and specific street addresses)
• Current Financial Statement
SECTION I – ACCOUNT INFORMATION
Mailing Address:
Physical Location Address:
Contact Person: Position:
Email Address: Phone Number: Fax Number:
Billing Contact Person: Phone Number:
Fein Number:
Effective Date: Is this account being quoted midterm? Yes No
Community Type:
Residential Condominium Cooperative Apartment Timeshare Apartment
Income Restricted Age Restricted Year Round Nursing Home Seasonal
# of Residential Buildings: Planned: # of Stories:
# of Residential Units: Planned: # of Timeshare Units:
Year Built: Year Converted/Renovated: Prior Occupancy:
Building Limit (Attach SOV): $
Deductible:
Coinsurance/Coverage: 80% 90% 100% Blanket Agreed Amount
Valuation Type: A/C/V Replacement Cost (RC) Extended RC Guaranteed RC
Business Personal Property: $
Deductible:
Maintenance Fees: $ Rents: $ Other Business Income:$
Condo Insuring Agreement:
Bare Walls Single Entity (Original Specs) All In (copy of insurance section of docs required)
Building Ordinance – Increased Cost of Construction $
Building Ordinance – Demolition cost $
Wind Deductible: $ Exclude Wind? Yes Where is wind being placed or quoted?
Earthquake: Limit $ $ Deductible: $ % Deductible: %
Flood: Flood Zone: Limit $ $ Deductible: $ % Deductible: %
Boiler Coverage desired Yes No Central Boiler? Yes No
Crime
Employee Dishonesty: $ Include Board of Directors Include Property Manager
Depositors Forgery: $
Computer Fraud: $
Money and Securities: $ In $ Out
Risk Management Contact:
Cell Phone:
Email:
SECTION II – RATING INFORMATION
Property
$2,500
$5,000
$10,000
$25,000
Other: $
$2,500
$5,000
$10,000
$15,000
Other:
Residential Application
Page 1 of 13
© 2018 Philadelphia Consolidated Holding Corp.
04/2018
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General Liability
Desired Limits:
$1,000,000 / $2,000,000
$1,000,000 / $3,000,000
$2,000,000/$4,000,000
Deductible:
$500
$1,000
$2,000
$5,000
Classification
ISO Code
Premium Basis
Condominiums – Residential
62003
Apartments
As applicable
Swimming Pools
48925
Clubhouse
41668
Parks or Playgrounds
46671
Lakes or Ponds
45524
Other:
Auto Liability
Indicate coverages desired:
Owned Auto (Attach ACORD) Non-Owned & Hired Auto
Garagekeepers Legal Liability
Comprehensive Collision
Employee Benefits
Employee Benefits coverage desired?
Yes
No
# of Employees:
Prior coverage in place?
Yes
No
If yes, number of years in place:
Retro date:
Type of plan(s):
Medical
Dental
401(k)
Other:
Umbrella
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
$10,000,000
$15,000,000
$20,000,000
Underlying Insurance
Carrier
Policy Dates
Limits
Employers Liability
$500,000/500,000/500,000
$100,000/500,000/100,000
Auto Liability
D& O Liability
Liability (other than package)
Square Footage
Total Building Area (not including area shown below):
Detached Garage Area:
Total Finished Basement Area:
Detached Carport Area:
Total Unfinished Basement Area:
Clubhouse Area:
Attached Garage Area:
Other:
Residential Occupancy
Current average sale or resell price of units:
$
Average Monthly Rate: $
# of owner occupied units:
# of rented units:
# of units rented for period shorter than 1 year:
# of seasonal owner units:
# of seasonal tenant units:
% Occupied: %
If seasonal, provide % occupancy:
Peak Season: %
Off Season: %
# of Association owned units:
#
Details:
Any one night rental units?
Yes
No
#
Details:
Any vacant units?
Yes
No
#
Details:
Any bank owned units?
Yes
No
#
Details:
Any developer owned units?
Yes
No
#
Details:
Any student occupied units?
Yes
No
#
Details:
Any subsidized housing units?
Yes
No
#
Details:
Any evictions past 3 years?
Yes
No
#
Details:
Dogs allowed?
Yes
No
#
Details:
Dog park with rules posted?
Yes
No
Are tenants provided with written statement of community policies and rules?
Yes
No
# of units
# of units
# of pools
Square Feet
# of parks or playgrounds
# of lakes or ponds
Residential Application
Page 2 of 13
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04/2018
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Are tenants required to obtain insurance?
Yes
No
Are Unit Owners required to maintain Individual Liability Insurance (HO6)?
Yes
No
If yes, what is the minimum limit of liability required?
$300,000
$500,000
$1,000,000
Other:
Commercial or Office Occupancy
Office
# of Office Units:
Square footage of office units:
Commercial
# of Commercial Units:
Square footage of commercial units:
Do any of the commercial units have a restaurant of commercial cooking exposure?
Yes
No
Management
Self managed
On site / property management firm
Off site / property management firm
Developer
Other:
If offsite management indicate frequency of site visits:
At least weekly
Other:
SECTION III – BUILDING INFORMATION
Construction Type
Frame
Joisted Masonry
Noncombustible
Masonry Noncombustible
Fire Resistive
Other (describe construction of floors , walls and roof )
Is exterior covered with dryvit, EIFS or aluminum siding?
Yes
No
If Frame, is siding wood shake?
Yes
No
Fire Protection and Alarms
Smoke detectors in common areas:
Hardwired
Battery
N/A (no common areas)
Smoke detectors in units:
Hardwired
Battery
CO Detectors?
Yes
No
Are unit owners periodically advised of Smoke Detector and CO Detector requirements?
Yes
No
Local fire alarm?
Yes
No
Central station fire alarm?
Yes
No
Annunciator panel?
Yes
No
Are there masonry firewalls?
Yes
No
If yes, number of units per firewall?
Are there 2 hour firewalls?
Yes
No
If yes, number of units per firewall?
Do all firewalls extend to underside of roof?
Yes
No
Please describe:
Name of Responding Fire Department:
Distance to nearest Responding Fire Department:
Public Protection Class:
For protection class 8 and 9, describe or attach fire suppression plan:
Sprinkler System
Yes
No
Type of sprinkler system(s):
Wet
Dry
Both
Classification:
NFPA 13
NFPA 13R
Other:
Areas of coverage:
Entire Building
Units
Common Areas
Attic
Basement
Garage
If applicable, are sprinkler pipes running through attic area insulated?
N/A
Yes
No
Percentage of building(s) sprinklered?
Is sprinkler piping fully insulated in exterior walls and attic areas to prevent freezing?
Yes
No
Any other freeze prevention measures?
Yes
No
If yes, please describe:
Does Applicant have a sprinkler system?
Residential Application
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Are sprinkler shutoff valves marked and readily accessible?
Yes
No
If no, please explain:
Is the sprinkler system tested and inspected by a sprinkler contractor annually?
Yes
No
Was a formal winterization review done?
Yes
No
Are sprinkler alarms tied to a 24-hour monitoring service?
Yes
No
Roof Type
Asphalt / Composition Shingle
If so, are any T-Lock shingles used?
Yes
No
Tile (clay)
Tile (concrete)
Metal
Wood Shake / Shingle
Flat (tar and gravel)
Flat (membrane)
Other:
Roof Manufacturer:
Roof Product:
Roof Warranty: years
Year of last roof update:
Are roofs inspected annually?
Yes
No
By whom:
Are roof replacements scheduled?
Yes
No
Please provide details or attach replacement schedule:
Do the roofs have ice shields installed?
N/A
Yes
No
How many feet?
Any ice damming history?
N/A
Yes
No
Corrective Actions taken:
HVAC equipment in attic space?
N/A
Yes
No
Clothes dryer vented into attic space?
N/A
Yes
No
Does attic area have adequate insulation and ventilation?
Yes
No
Energy Star minimum requirements:
http://www.energystar.gov/?c=home_sealing.hm_improvement_insulation_table
Electrical
Any Aluminum wiring other than main feeds?
Yes
No
If aluminum wiring, has retrofitting been done by a licensed electrician?
Yes
No
Corrective method used:
None
COPALUM crimp
AlumniConn
CO/ALR Devices
Date retrofit complete:
Provide documentation of work completed or written confirmation from installing contractor.
Are circuits protected by circuit breakers?
Yes
No
If no or Federal Pacific Breakers please explain and provide details on replacement program.
Are there any fuses or fuse stats?
Yes
No
If yes, please explain:
Provide details on any electrical service updating projects affecting multiple units:
Does the property contain Photovoltaic (Solar) Panels?
Yes
No
If yes, complete the Solar Panel Supplemental Application.
Residential Application
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04/2018
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Plumbing
Is there Polybutylene piping?
Yes
No
Please provide details on replacement program:
Any water heater replacement programs?
Yes
No
Please provide details on replacement program:
Any washer hose replacement program?
Yes
No
Please provide details on replacement program:
Provide details on any plumbing updating projects affecting multiple units:
Are there water pipes that run through exterior walls?
Yes
No
If yes, are they insulated?
Yes
No
Is domestic water piping fully insulated in exterior walls and attic areas to prevent freezing?
Yes
No
Any other freeze prevention measures?
Yes
No
If yes, please describe:
Are main water shutoff valves marked and readily accessible?
Yes
No
Are individual building / unit water shutoff valves marked and readily accessible?
Yes
No
If no, please explain:
Any water flow detection, notification or automatic shutoff devices?
Yes
No
Any maintenance staff or individuals on 24-hour call to shut off water main in event of emergency?
Yes
No
Any formal procedures to require domestic water lines to be drained or turned off for any vacant or
unoccupied units?
Yes
No
Heating, Ventilation and Air Conditioning (HVAC)
Any Boilers?
Yes
No
Date of last inspection (month/year)?
Any fire places?
Yes
No
Regular cleaning required?
Yes
No
Any wood stoves?
Yes
No
Central HVAC?
Yes
No
Provide details on any HVAC updating projects affecting multiple units:
Describe any provisions to maintain heat in unoccupied units:
Are there water pipes in exterior walls?
Yes
No
If yes, are they insulated?
Yes
No
What minimum temperature are unit owners / tenants advised to maintain when unit is unoccupied?
Residential Application
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04/2018
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Means of Egress (buildings over 3 stories)
All interior stairwells masonry enclosed?
Yes
No
All interior stairwells have fire doors?
Yes
No
Are fire doors equipped with panic hardware?
Yes
No
Exterior fire escapes?
Yes
No
Emergency lighting in hallways and stairwells?
Yes
No
Elevators?
Yes
No
# of passenger # of freight
Are there illuminated exit signs?
Yes
No
# of exits per building?
Asbestos
Any asbestos exposures in buildings?
Yes
No
Ceilings
Floors
Boiler Room
Pipe insulation
Other:
Describe:
Lead
Any lead exposures in building?
Yes
No
Describe remediation work:
Miscellaneous Building Issues
Is grilling on balconies permitted?
Yes
No
Charcoal
Propane
Other:
Any known or suspected construction defects:
Yes
No
Describe defect and remediation work:
Any outstanding insurance company risk management recommendations?
Yes
No
Please provide details on recommendations and work planned:
Any buildings built on pilings?
Yes
No
SECTION IV – LIABILITY INFORMATION
Age Restricted Community
N/A
Any medical services provided?
Yes
No
Please describe:
Any assisted living facilities?
Yes
No
Please describe:
Security
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.
Residential Application
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04/2018
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Are the premises monitored by a closed circuit TV?
Yes
No
Is this a gated community or gated property?
Yes
No
If yes, please describe access:
Describe any fixed security measures in place. (i.e. window security in place, cards, locks, sliding
glass doors, etc.)
Are incident reports provided to senior management of the property management company for
security improvement actions plans to be implemented?
Yes
No
What process is followed after a violent attack takes place?
Are criminal background checks conducted on all tenants and employees?
Yes
No
Clubhouse
N/A
Indicate Clubhouse Exposures:
Cooking Facilities
Food Service
Liquor Service
Pro Shop
Indoor Pool
Spa
Convenience Store
Retail Store
Other:
Is the clubhouse rented out?
Yes
No
If yes, to whom?
Residents
Public
Formal rental agreement used?
Yes
No
Swimming Pool
N/A
Are there any swimming pools?
Yes
No
Number of adult pools:
Number of wading pools:
Are all swimming pools and spas compliant with Virginia Graeme Baker Pool and Spa Safety Act?
Yes
No
If no, provide time table and action plan:
Are there any indoor pools?
Yes
No
Are there any pools on an upper floor or rooftop?
Yes
No
Are there any diving boards?
Yes
No
Number of diving boards:
Highest diving board:
Are there any slides?
Yes
No
Number of slides (attach photo):
tube:
Other:
Are there any Spas or Whirlpools?
Yes
No
If yes, is the spa/whirlpool located in the pool area?
Yes
No
Are spa/whirlpool health risk signs posted?
N/A
Yes
No
Can the pool be rented out for private functions?
Yes
No
Are pools completely fenced?
Yes
No
Do you have a self locking / latching gate that is in proper working condition?
Yes
No
Are all doors / gates leading to the pool area locked after hours?
Yes
No
Is public access to the pool area controlled by a secure door or gate?
Yes
No
What are the hours of operations?
Are lifeguards on duty during posted hours?
Yes
No
Are the hours posted?
Yes
No
Are lifeguards:
Employees
Sub-contracted
If sub-contracted, is a current certificate of insurance obtained?
Yes
No
Is a written maintenance schedule check done on all life safety features daily?
Yes
No
Who is responsible for daily maintenance?
Are SWIM AT YOUR OWN RISK signs posted?
Yes
No
Are pool depths marked in and around the pool area?
Yes
No
Residential Application
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Is motorized boating allowed?
Yes
No
Are signs posted indicating prohibited activities?
Yes
No
Dams
N/A
Number of dams:
Types of dams:
Number of acres:
Comment on downstream exposure and attach dam inspectors report:
Playground
No Playground Exposure
What is the surface under the playground equipment?
Amenities and Recreational Activities
N/A
Are any child care services permitted?
Yes
No
Is skateboarding permitted?
Yes
No
If no, are signed posted?
Yes
No
Is there an equestrian exposure?
Yes
No
If yes, please provide details:
Is there any high hazard activities?
Yes
No
If yes, please provide details:
Number of courts for:
Tennis?
Basketball?
Volleyball?
Walking or Biking Trails?
Yes
No
Number of miles:
Is there an exercise / weight room?
Yes
No
If yes, is it supervised?
Are rules posted?
Yes
No
Type of equipment:
Free Weights
Circuit equipment
Step Machine
Lifecycle
Treadmills
Rowing machines
Other:
Golf Course / Driving Range
N/A
Association owned golf course or driving range?
Yes
No
Is the golf course / driving range open to the public?
Yes
No
Is the golf course operated and maintained by an independent contractor?
Yes
No
Maintenance and Independent Contractors
Are there any hire maintenance work done for individual unit owners?
Yes
No
If yes, please describe:
SECTION V – CRIME INFORMATION
What is the current operating budget?
Who handles association funds?
Board of Directors
Property Manager
Accounting Firm
Does property manager commingle association funds with other associations?
N/A
Yes
No
Does property manager carry fidelity coverage?
N/A
Yes
No
Property manager check signing limit without countersignature?
N/A
Limit $
Yes
No
Lakes or Ponds
N/A
Are there any ponds?
Yes
No
Number of ponds:
Size of pond(s):
Acres:
Depth: Feet
Are there any lakes?
Yes
No
Number of lakes:
Size of lake(s):
Acres:
Depth: Feet
Is the lake owned by the association?
Yes
No
Confined by dam, levy or dyke?
Yes
No
Is swimming permitted?
Yes
No
Is swimming restricted to designated area?
Yes
No
Is the area roped off?
Yes
No
Are lifeguards on duty during posted hours?
Yes
No
Are lifeguards:
Employees
Sub-contracted
If sub-contracted, is a current certificate of insurance obtained?
Yes
No
Is ice skating allowed?
Yes
No
Is fishing allowed?
Yes
No
Is non-motorized boating allowed?
Yes
No
Residential Application
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Association fees and assessments are sent to: Association Property Manager
Lock Box
Are there separate operating and reserve accounts?
Yes
No
Is prior board approval required for all expenditures?
Yes
No
Is prior board approval needed to access reserve account?
Yes
No
Are countersignatures required on all checks?
Yes
No
Is a board member signature required for countersignature?
Yes
No
If no, explain procedure:
Is there an annual audit?
Yes
No
What type (i.e. certified, compilation)?
Are bank statements reconciled monthly?
Yes
No
If no, indicate frequency:
Does the person who reconciles have the ability to withdraw funds?
Yes
No
Does the association have debit or credit card accounts?
Yes
No
Who has cards?
SECTION VI – AUTOMOBILE INFORMATION
If scheduled automobiles, submit ACORD applications, driver schedule and MVR’s.
Are any vehicles used for transportation for residents to and from areas of interest?
Yes
No
If yes, provide details:
Is owned auto coverage desired?
Yes
No
If yes, provide ACORD Auto Application and MVRs.
Any unlicensed or unregistered vehicles?
Yes
No
Describe use and circumstances:
If no, over what amount?
$
If no, indicate $ threshold:
$
SECTION V – CRIME INFORMATION
What is the current operating budget?
Who handles association funds?
Board of Directors
Property Manager
Accounting Firm
Does property manager commingle association funds with other associations?
N/A
Yes
No
Does property manager carry fidelity coverage?
N/A
Yes
No
Property manager check signing limit without countersignature?
Limit $
Does maintenance person routinely walk premises to inspect and address imminent hazard
(i.e. weather related slip and fall hazards)?
Yes
No
Has a reserve study or a plan for funding major maintenance projects been done?(attach)
Yes
No
Are association streets:
Private
Public
If private streets, who maintains?
Association
Independent Contractor
Indicate existing maintenance contracts:
Grounds
Maintenance
Snow Removal
Indicate if contractor provides:
Written Contract
Hold harmless
Certificate of Insurance
If there is a Snow Removal contract, does it include a hold harmless / indemnification clause
protecting the Association?
Yes
No
Residential Application
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SECTION VII – PRIOR CARRIER INFORMATION
General Liability
Carrier
Policy Number
Policy Type
Claims
Made
Occ
Claims
Made
Occ
Claims
Made
Occ
Claims
Made
Occ
Retro Date
Effective / Exp Date
L
I
M
I
T
S
General Aggregate
Products Comp Op
Aggregate
Personal Adv Injury
Fire Damage
Medical Expense
Bodily
Injury
Occ.
Agg.
Property
Limit
Occ.
Agg.
CSL
Premium
Automobile Liability
Carrier
Policy Number
Policy Type
Effective / Exp. Date
Combined Single Limit
Bodily
Injury
Ea Person
Ea Accident
Property Damage
Premium
Property
Carrier
Policy Number
Policy Type
Effective / Exp Date
Building AMT
Pers Prop AMT
Premium
Coverage:
Carrier
Policy Number
Policy Type
Effective / Exp Date
Limit
Premium
Residential Application
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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 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 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
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)
Residential Application
Page 11 of 13
© 2018 Philadelphia Consolidated Holding Corp.
04/2018
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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
Residential Application
Page 12 of 13
© 2018 Philadelphia Consolidated Holding Corp.
04/2018
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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
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KN
OWINGLY 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 (PL
EASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
____________________________________________________
SIGNATURE DATE
SECTION TO B
E COMPLETED BY THE PRODUCER/
BROKER/AGENT
PRODUCER AGE
NCY
(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)
Residential Application
Page 13 of 13
© 2018 Philadelphia Consolidated Holding Corp.
04/2018
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Application - Residential36-9178

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Completed 2 July 2020

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