SALON AND DAY SPA
GENERAL LIABILITY AND PROPERTY APPLICATION
SUBMISSION REQUIREMENTS
Completed, signed, and dated PHLY Salon and Day Spa Supplemental application
Currently valued insurance company loss runs for the current policy period plus three (3) prior years
If none, a No Loss Letter is required
Website Address
Copy of Service Menu or Brochure
Copy of Resume if in business less than three (3) years
If any of the following services are provided, you are not eligible for this program: Acupuncture,
Permanent Make-Up, Chiropractic, Tattooing, Laser Hair Removal, Botox or Injections of any kind.
GENERAL INFORMATION
Legal Business Name:
Doing Business As (DBA):
Applicant’s Name:
Contact Name:
Business Entity:
LLC
Sole Proprietorship
Partnership
Corporation
Non Profit
Physical Address:
City:
State:
Zip:
County:
Is the location a private residence?
Yes
No
If yes, is there a separate entrance? Please explain.
Yes
No
Number of Locations:
(Complete a separate application for each location)
Check here if mailing address is the same as location address.
Mailing Address:
City:
State:
Zip:
County:
Telephone:
Fax:
E-mail:
Website:
Risk Management Contact:
Risk Management’s Phone:
Risk Management Email:
Requested effective date:
PREVIOUS CARRIER INFORMATION
CARRIER
EXPIRATION
ANNUAL PREMIUM
Property
$
General Liability
$
Crime
$
1.
Has the Applicant been cancelled or non-renewed? If yes, explain.
Yes
No
Fitness and Wellness Insurance ● A Member of Philadelphia Insurance Companies
Salon and Day Spa GL and Property Application
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GENERAL LIABILITY*
Multiple locations must complete a separate application for each location
*General Liability coverage is written through the Fitness & Wellness Risk Purchasing Group. A Fee is required to join this Risk
Purchasing Group. This fee may vary, but the exact amount will be indicated on your proposal and / or invoice.
1.
Type of facility:
Day Spa
Destination Spa
Check if also a Fitness Facility
2.
Does the Applicant’s business engage in operations not day spa related? If yes, explain.
Yes
No
3.
Years in Business:
4.
Gross Annual Revenues: $
5.
Gross Payroll: $
6.
Square Footage:
7.
Total number of Members / Clients:
8.
Monthly Membership Dues: $
Liability Coverages and Limits
Commercial General Liability / Professional Liability
Personal and Advertising Injury Liability
1.
Occurrence / Aggregate Limit (please indicate):
$1,000,000 / $2,000,000
$1,000,000 / $3,000,000
Umbrella:
Yes
No
Limit: $
2.
Sexual Abuse Liability $100,000 per occurrence / $300,000 aggregate
3.
Tenant Legal Limit (please indicate):
$100,000
$300,000
4.
Medical Payments (please indicate):
$1,000
$5,000
5.
Non-Owned and Hired Automobile Liability:
Yes
No
6.
Stop Gap: (ND, WA, WY, OH)
Yes
No
7.
Is the Applicant’s current General Liability or Professional Liability written on an:
Occurrence Basis
Claims Made Basis
If claims made, what is the retroactive date:
OPERATIONS
1.
Please check the professional services that the Applicant performs and for which the Applicant desires
coverage under the policy.
NOTE: Any professional service for which the Applicant does not provide such information will not be covered
under the policy.
NOTE: Checking a professional service does not obligate us to insure it.
Aromatherapy
Facial and Skin cleansing
Body massage
Facial scalp massage
Body Piercing (other than ear lobe)
Hair cutting/styling/coloring
Body wraps for weight/water reduction
Hydrotherapy
Body wraps for other than weight/water reduction
Manicure or pedicure
Cosmetics / Make-up application
Micro-dermabrasion**
Ear piercing
Teeth whitening
Electrolysis
LED teeth whitening only
Endermology
Waxing
Chemical Peels Please indicate the highest acidity level used in facials:
Please list the highest percentage of Alpha Hydroxy or Beta Hydroxy used in facials: %
Please list any acids used that are not Alpha Hydroxy or Beta Hydroxy (Phenol Acid, Trichloraecetic
“TCA” Acid, etc.):
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**
If the Applicant offers micro-dermabrasion, you must confirm that any staff performing this service are
licensed aestheticians and each are certified by the manufacturer. Check here if yes.
If no, explain:
2.
Please provide the percentage of revenue
Tanning:
%
Hair Services:
%
Massage:
%
Manicure/Pedicure:
%
Product Sales:
%
3.
Provide the number for each:
Employees (part-time is less than 10 hours/week) and independent contractors. Do not include the owner.
Staff
Employees:
(Part-time is less than 10 hrs/wk)
Independent Contractors
Full-time
Part-time
Full-time
Part-time
Aestheticians
Masseuse
Body wrap technicians
Manicurists
Beauticians
Electrologist
Pilates instructors
Yoga instructors
Fitness instructors
Aerobic instructors
Students (Aesthetician or Electrologist)
Office Staff
TOTAL:
Exposures and Equipment
1.
Please provide the number of the following:
Equipment
Number
Exercise equipment (NOT including free weights and mats)
Hydrotherapy Tables/Tubs/Floatation Tanks
Jacuzzis
Steam/Sauna
Swimming Pools
Are all swimming pools and spas compliant with the Virginia Graeme Baker Pool and
Safety Act? If no, provide a time table and action plan:
Yes
No
Diving Boards?
Yes
No
Tanning Beds/Booths?
Yes
No
If yes, how many:
If yes:
Are goggles required?
Yes
No
Are token timers used?
Yes
No
Are operators present?
Yes
No
Are controls on the outside of the booth / bed?
Yes
No
Are tanning booth waivers signed by members?
Yes
No
Are only the manufacturer suggested bulbs used?
Yes
No
Type of bulbs used: UVA: % UVB: %
Are warning signs posted regarding ultraviolet rays?
Yes
No
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2.
Are all technicians licensed if required by law?
Yes
No
3.
Does the Applicant’s equipment comply with and is the Applicant aware of all requirements
of federal and state regulatory agencies?
Yes
No
4.
How many Automatic External Defibrillators (AEDs) do you have at each location:
5.
How many employees at each location are trained to operate an AED:
6.
Was full CPR training a part of the AED training?
Yes
No
7.
Do independent contractors or booth renters conduct operations on your premises?
Yes
No
8.
Are the work areas where acrylics are used well-ventilated?
Yes
No
9.
Do all employees receive safety instruction to avoid potential eye contamination by
chemicals?
Yes
No
10.
Are all body contact supplies sanitized after each use?
Yes
No
11.
Are toxic chemicals stored away from the access of customers?
Yes
No
12.
Does the Applicant provide on-site child care for customers or employees? (This is not a
covered hazard.)
Yes
No
13.
If the Applicant’s clients operate any exercise equipment, are they instructed and
monitored?
Yes
No
14.
Does the Applicant manufacture or re-package any product?
Yes
No
15.
Is any product manufactured and distributed under the Applicant’s private label?
Yes
No
If yes, please describe the product and attach proof of manufacturer coverage:
16.
Does the Applicant mandate that employees stay up to date with their certifications?
Yes
No
If yes, how often?
17.
Does the Applicant use and save as a permanent record, a hazard disclosure and personal
injury disclaimer or waiver for each customer for all services performed?
Yes
No
18.
How often are client intake forms requested?
19.
Are off premise laundry services used?
Yes
No
If yes, how often?
Is a certificate of insurance collected to verify coverage?
Yes
No
20.
Does the Applicant have a medical crisis plan?
Yes
No
21.
Does the Applicant require health histories, intake questionnaires?
Yes
No
If yes, how long are they kept:
22.
Does the Applicant require signed waivers / client intake forms from all clients?
Yes
No
23.
Is signage used throughout the facility to prevent injury?
Yes
No
24.
Does the Applicant have non-slip surfaces in all wet areas?
Yes
No
25.
Does the Applicant’s facility have a restaurant / snack bar? If yes, please explain:
Yes
No
26.
Does the Applicant sub-lease space to others? If yes, please explain:
Yes
No
27.
Is there a retail shop?
Yes
No
What are the hours of operation:
Is staff present during all hours of operation?
Yes
No
Abuse and Molestation
1.
Does the Applicant’s employment process (for employees and volunteers) 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 Applicant’s state permit you to do criminal background investigations?
Yes
No
If yes, does the Applicant routinely request and receive such background investigations?
Yes
No
4. Does the Applicant verify employment-related references? Yes No
5. Does the Applicant conduct a personal interview? Yes No
6. Does the Applicant have written procedures for dealing with sexual abuse? Yes No
If yes, attach a copy.
7. Does the Applicant have a plan of supervision that monitors staff in day-to-day relationships
with clients, both on and off premises? Yes No
3. Will any independent contractors have access to clients or children in a closed door setting
or perform operations where they will be physically touching another person? Yes No
a. Does the Applicant perform background checks on hired independent contractors? Yes No
b. If no, please explain:
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8.
Has the Applicant ever had an incident which resulted in an allegation of sexual abuse?
Yes
No
If yes, describe:
Day Nursery/Babysitting
1.
Are waivers signed by parents?
Yes
No
2.
Ratio of staff to children:
3.
Qualifications of staff:
4.
Activities occurring:
Is there a playground?
Yes
No
If yes, type of equipment:
If outdoor, what type of surface is under the equipment:
What type of supervision is given to the playground:
Additional Insureds
Eligible Additional Insured criteria include landlords, property managers, equipment rental companies, mortgagees
and lien holders.
Name:
Type of Insured:
Address:
City:
State:
Zip Code:
E-Mail:
Telephone Number:
PROPERTY SECTION
Check this box if you DO NOT WANT property coverage and proceed to signature page.
Multiple locations must complete a separate application for each location.
Property coverage cannot be purchased on stand-alone basis
Building(s)
Loc. No.
Bldg. No.
ACV/RC
Limit of Insurance
Coinsurance
$
90%
Contents
Loc. No.
Bldg. No.
ACV/RC
Limit of Insurance
Coinsurance
$
90%
Tenant Improvements and Betterments
Loc. No.
Bldg. No.
ACV/RC
Limit of Insurance
Coinsurance
$
90%
Deductible
$500
$1,000
Other: $
Business Income
Loc. No.
Bldg. No.
ALS
Limit of Insurance
Coinsurance
$
50%
Monthly Limit of Indemnity Form also available. If desired, please indicate the following:
Monthly Limitation:
1/3
1/4
1/6
(No coinsurance clause)
REQUIRED UNDERWRITING INFORMATION
1.
Construction of Building
Number of Stories:
Walls:
Wood Frame
Brick / Brick
Steel Frame
Other:
Roof:
Wood Frame
Poured Concrete
Steel Frame
Other:
Floor:
Wood Frame
Concrete
Other:
2.
Year Built:
Square Footage:
Age of Roof:
If building is over 25 years old, provide year of update for:
Roof:
Wiring:
Plumbing:
Heating:
Fitness and Wellness Insurance ● A Member of Philadelphia Insurance Companies
3. Does the Applicant have any air supported fabric roof structures on premise? (Tennis
bubbles, Event tents, etc…) Yes No
4. Yes No
Central Station with Keys Central Station without Keys
Burglar Alarm:
If yes,
Fire Alarm Yes No If yes, Central Station Local Gong
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5.
Does the property have automatic fire sprinklers?
Yes
No
6.
Distance from building to: Fire Hydrant:
Fire Station (miles):
7.
Does the property have aluminum wiring?
Yes
No
If yes, has it been retrofitted with one of the PHLY approved connectors and by a licensed
electrician? Indicate which one:
Yes
No
COPALUM
Yes
No
AlumiConn
Yes
No
Date updated:
Please supply retro-fit documentation or statement from installing contractor.
8.
Does the Applicant own the building?
Yes
No
If no, who does:
9.
Mortgagee:
10.
Loss Payee:
11.
Signs
Type
Value
Location
1.
$
2.
$
3.
$
Flood
12.
Does the Applicant have a current flood policy in force?
Yes
No
If yes, attach a copy of the declarations page.
If no, would you like a flood quote with our proposal?
Yes
No
(Flood quote will be secured through the Write Your Own Flood Program)
Crime
13.
Theft, Disappearance and Destruction
$
14.
Loss Inside the Premises
$
Loss Outside the Premises
$
15.
Employee Dishonesty:
$
16.
Number of officers and employees who have custody of the money:
17.
By whom is financial audit completed:
18.
Frequency of audits:
19.
Is there a countersignature procedure in place?
Yes
No
20.
Frequency of bank deposits:
21.
Are accounts reconciled by someone not authorized to deposit or withdraw monies?
Yes
No
The insurer may not be subject to all insurance laws and regulations of this state. The member benefits
described are guaranteed through an insurance contract. The Fitness and Wellness Risk Purchasing Group's
insurance policy is underwritten by Philadelphia Indemnity Insurance Company.
Fitness and Wellness Insurance ● A Member of Philadelphia Insurance Companies
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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 PRO
DUCER/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)
Fitness and Wellness Insurance ● A Member of Philadelphia Insurance Companies
Salon and Day Spa GL and Property Application
Page 7 of 9
© 2016 Philadelphia Consolidated Holding Corp.
12/2016
CYBER SECURITY LIABILITY ENDORSEMENT SUPPLEMENTAL
QUESTIONNAIRE (FOR LIMITS $250,000 OR LESS)
Applicant Name:
Mailing Address:
City:
State:
Zip:
Website: www:
1.
Nature of Operations:
2.
Annual sales or revenue: $
3.
Does the Applicant collect, store or otherwise handle any Personally Identifiable Information (PII)
belonging to customers, clients, or other third parties, other than employees?
Yes
No
If yes, please indicate the types of Personally Identifiable Information held. (check all that apply):
Social Security Numbers, Bank or Other Financial Account Details, Driver’s License or other
State Identification Numbers
Non-Public Medical or Healthcare Data, including Protected Health Information (PHI)
Credit or Debit Card Information
4. 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
l
awsuit against the Applicant alleging invasion or interference of rights of privacy or t
he
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
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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
AN
Y 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.
N
AME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
____________________________________________________
SIGNATURE DATE
S
ECTION TO BE COMPLETED BY THE
PRODUCER/BROKER/AGENT
P
RODUCER 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)
Salon and Day Spa GL and Property Application
Page 9 of 9
© 2016 Philadelphia Consolidated Holding Corp.
12/2016
Fitness and Wellness Insurance ● A Member of Philadelphia Insurance Companies
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