Fillable Application - Vocational Schools Supplemental36-11171 Vocational Schools Supplemental Application

Fill Online, Printable, Fillable, Blank Application - Vocational Schools Supplemental36-11171 Vocational Schools Supplemental Application Form

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

Application - Vocational Schools Supplemental36-11171 Vocational Schools Supplemental Application

On average this form takes 116 minutes to complete

The Application - Vocational Schools Supplemental36-11171 Vocational Schools Supplemental Application form is 8 pages long and contains:

  • 0 signatures
  • 48 check-boxes
  • 440 other fields

Country of origin: US
File type: PDF

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

BROWSE PHILADELPHIA INSURANCE COMPANIES FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Vocational Schools Supplemental
SUBMISSION REQUIREMENTS
• ACORD Application (for lines of coverage to be written)
• Currently Valued, Hard Copy Loss Runs
•
Statement of Values (for blanket and/or agreed value)
•
Audited Financial Statement
•
List of Faculty Members by Position
•
Schedule of Vehicles
•
Brochure, Handbook, Student Application
•
Drivers List with License # and DOB
This application consists of the following sections:
Section I – General Information
Section V – Driving Schools
Section II – Security
Section VI – Music, Dance & Art Schools
Section III – Cosmetology/Beauty Schools
Section VII – Dormitories
Section IV – Culinary Schools
Section VIII – Abuse & Molestation
GENERAL APPLICANT INFORMATION
Applicant’s Name:
Mailing Address:
City:
State:
Zip:
Website: www.
Effective Date:
Risk Management Contact:
Risk Management’s Phone:
Risk Management Email:
SECTION I – GENERAL INFORMATION
Total Number of students enrolled:
Average daily attendance:
Date school founded or chartered:
School is:
For Profit
Not For Profit
Programs / Classes / Degrees offered (list or attached):
Is the Applicant’s institution accredited?
Yes
No
If yes, what is the name of the association(s) that provides the accreditation?
Are all programs offered at the schools accredited by the above listed association(s)?
Yes
No
Is the Educational Institution accredited?
Yes
No
If yes, list accrediting organization(s): (check all that apply)
Middle States Commission on Higher Education
New England Association of Schools and Colleges Commission on Institutions of Higher Education
North Central Association of Colleges and Schools The Higher Learning Commission
Northwest Commission on Colleges and Universities
Southern Association of Colleges and Schools Commission on Colleges
Western Association of Schools & Colleges Accrediting Commission for Community & Junior Colleges
WASC Senior College and University Commission
New York State Board of Regents
Accrediting Council for Independent Colleges and Schools
Distance Education and Training Council Accrediting Commission
Association for Biblical Higher Education Commission on Accreditation
Association of Advanced Rabbinical and Talmudic Schools Accreditation Commission
The Association of Theological Schools in the United States and Canada Commission on Accrediting
Transnational Association of Christian Colleges and Schools Accreditation Commission
Other:
Vocational Schools Supplement
Page 1 of 8
© 2017 Philadelphia Consolidated Holding Corp.
05/2017
Clear Application
Print Application
Date of most recent review:
What was the outcome of the most recent review?
Accreditation Continued
Denial of Accreditation
Warning
Accreditation Continued –
follow-up report requested
Probation
Withdrawal of Accreditation
Appeal
Show Cause
Other:
Are all programs offered at the schools accredited by the above listed association(s)?
Yes
No
Have any programs or degrees been accredited by additional specialist agencies?
Yes
No
If yes, please attach a listing of the program or degrees and the specialist agency.
Does the Educational Institution offer job placement services for students?
Yes
No
If yes, is there a disclaimer signed by students acknowledging that there is no job placement
guarantee?
Yes
No
What is the Educational Institution’s course completion rate?
%
What is the Educational Institution’s job placement rate?
%
What is the Educational Institution’s loan default rate?
%
What is the percentage of online courses?
%
Has the Educational Institution or any of the Educational Institution’s academic programs ever
lost accreditation, been placed on probation or become unable to gain accreditation?
Yes
No
In the last 12 months, has the Educational Instituting eliminated or closed any academic
programs, including music, arts or athletic programs?
Yes
No
In the next 12 months, does the Educational Institution anticipate eliminating or closing any
academic programs?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Does the Applicant’s students serve time as interns / externs at outside companies / business?
If yes, are the students paid?
If students are paid, does the Applicant verify that the employer carries workers’ compensation
coverage to cover the Applicant’s student?
If students are not paid, does the intern / extern company ask to be additional insured on the
Applicant’s liability policy?
Please attach any internship / externship contracts the Applicant signs with outside
businesses.
Does the Applicant sign any hold-harmless agreements with anyone?
Yes
No
If yes, please explain for whom and for what reason:
Does the Applicant provide services for outside customers?
Yes
No
If yes, what services do you provide:
How are students supervised:
What quality controls measures are in place:
Are customers required to sign an agreement acknowledging they’re using student labor?
Yes
No
Does the Applicant have dormitories?
Yes
No
If yes, please complete section VII of the application.
Does the Applicant have a cafeteria or restaurant on premises?
Yes
No
Does the Applicant cook on premises?
Yes
No
Does cooking protection comply with NFPA 96 requirements?
Yes
No
Does the Applicant ever serve liquor on premises?
Yes
No
Is the manual pull for extinguishing system readily accessible?
Yes
No
Are there portable fire extinguishers in the kitchen area?
Yes
No
Are there laboratories present in the school?
Yes
No
Is the laboratory sprinklered?
Yes
No
Are fire extinguishers present?
Yes
No
Are chemicals stored in a locked area?
Yes
No
Is proper safety apparel worn by students (goggles, masks, gloves)?
Yes
No
Is the public ever invited on premise?
Yes
No
If yes, explain how often and for what purposes:
Vocational Schools Supplement
Page 2 of 8
© 2017 Philadelphia Consolidated Holding Corp.
05/2017
Clear Application
Print Application
Does the Applicant use volunteers?
Yes
No
If yes, explain how often and for what purposes:
Does the Applicant have a medical facility/infirmary and/or dispense medication?
Yes
No
Does the facility provide only immediate care/first aid?
Yes
No
Does the facility only serve students and employees?
Yes
No
Are there only over the counter drugs stored on premises?
Yes
No
Are written instructions from parents required prior to dispensing any medications to
minors?
Yes
No
Is there any overnight care provided?
Yes
No
How many beds are in the infirmary:
Are there written operational procedures in place?
Yes
No
Is there a medical professional on staff?
Yes
No
If yes, indicate which of the following and how many are employed by the insured. (Check all that apply)
RN:
Psychologist:
Physician:
Nurse Practitioner:
Dentist:
Physical Therapist:
Counselor:
Does the professional carry their own malpractice insurance?
Yes
No
If yes, who is the carrier and what limits are carried:
Is medical history and care records kept for each patient?
Yes
No
Does the Applicant’s organization utilize GPS fleet telematics devices?
Yes
No
If yes, please check off the fleet telematics being utilized:
Plug in
Hard wired
Mobile Phone
Other:
What percentage of the Applicant’s fleet is provided with these fleet telematics devices? %
SECTION II – SECURITY
Are there security guards at the school daily?
Yes
No
Indicate the number of personnel providing security services
Employed:
Unarmed Security:
Armed Security:
Contracted:
Unarmed Security:
Armed Security:
When security is contracted to a third party, is the contractor’s general liability/law enforcement
professional liability policy required to name the educational institution as an additional
insured?
Yes
No
If yes, does the third party maintain a minimum limit of liability coverage and indemnify
the educational institution?
Yes
No
If yes, indicate the minimum limit of liability of general/police professional liability
coverage your institution requires: $
Do security personnel have arresting authority?
Yes
No
If there is employed armed security, are they trained and/or re-certified annually to the
standards required for public sector law enforcement personnel within the political subdivision
for use of weapons?
Yes
No
Are criminal background checks and psychological reviews provided for all employed security?
Yes No
months.
If yes, how often are these checks and reviews conducted: Every
If no, explain:
Is the Applicant’s Security Department accredited by the International Association of Campus
Law Enforcement Administration (IACLEA)?
Yes
No
Does a mutual aid agreement exist with local city or county police?
Yes
No
Does the Applicant permit staff, students, volunteers, or visitors to carry open or concealed
firearms on your premises?
Yes
No
If the Applicant does not permit open and/or concealed carry of firearms on any premises for
which the Applicant is requesting insurance coverage, do all locations have signage which
conspicuously identifies the building as a Gun Free Zone?
Yes
No
Do security personnel store weapons on premises?
Yes
No
Do faculty, staff, or employees store weapons on premises?
Yes
No
Does the Applicant’s weapons ban policy have any exceptions?
Yes
No
If yes, please provide a copy.
Does the Applicant have emergency call boxes located throughout the campus that are
connected directly to campus security or policy?
Yes
No
Does the Applicant provide after-hours security escort service for students?
Yes
No
Vocational Schools Supplement
Page 3 of 8
© 2017 Philadelphia Consolidated Holding Corp.
05/2017
Clear Application
Print Application
SECTION III – COSMETOLOGY / BEAUTY SCHOOLS
N/A
Are all flammable hair solutions and cleaning supplies stored away from heat sources?
Yes
No
Are combs and brushes sterilized in between uses?
Yes
No
Do students and instructors wear protective gloves or use barrier creams when handling
permanent wave preparations to prevent skin irritation and skin disease?
Yes
No
Is there adequate ventilation?
Yes
No
What is the length of the program:
Is the public ever invited onto the premises?
Yes
No
If yes, please explain:
Does the school offer free or discounted services to the public?
Yes
No
If yes, please explain:
Are total receipts from public beauty services 10% or less of the total receipts?
Yes
No
Are there any operations conducted off premises?
Yes
No
If yes, please explain:
SECTION IV – CULINARY SCHOOLS
N/A
Type of facility:
School w/liquor
School w/out liquor
Is the school part of a chain or franchise?
Yes
No
Has the school ever been charged with a violation of any board of health regulations?
Yes
No
If yes, please explain:
Does cooking protection comply with NFPA 96 requirements?
Yes
No
Is there an Automatic fire extinguishing system providing surface protection from all
cooking surfaces (griddles, ranges, deep fry and boilers)?
Yes
No
Are there metal hoods and ducts covering all cooking surfaces?
Yes
No
Are hoods equipped with removable filters or grease extractors vented to the outside of
the building?
Yes
No
Are cooking or heating devices installed with a minimum of 18 inches of safe clearance
to combustible walls, ceilings, etc.?
Yes
No
Is the manual pull for the extinguishing system readily accessible and clearly identified?
Yes
No
Are all gas fired cooking equipment and appliances equipped with automatic fuel shut off?
Yes
No
Are all deep fat fryers equipped with thermostats that automatically shut fuel off, set to
do so at 475 degrees?
Yes
No
Are there portable fire extinguishers in the kitchen area?
Yes
No
Is the public ever invited onto the premises?
Yes
No
If yes, please explain:
Does the school offer free or discounted meals to the public?
Yes
No
If yes, please explain:
Is there an eating facility on the premises?
Yes
No
If yes, what type:
SECTION V – AUTOMOBILE / DRIVING SCHOOLS
N/A
1.
Does the Applicant use an independent school bus contractor to transport students?
Yes
No
a.
If yes, are Certificates of Insurance required from the contractor?
Yes
No
If yes, attach Certificate of Insurance.
b.
Is the school an additional insured on the contractor’s policy?
Yes
No
2.
Does the Applicant hire or borrow vehicles for non-busing purposes?
Yes
No
If yes, please describe purpose and length of time vehicles are hired or borrowed:
3.
Approximately how many cars are hired or borrowed annually?
Total cost of hire, bus contractors: $
Total cost of hire, other: $
4.
Are any buses leased or loaned to others or used by outside organizations?
Yes
No
If yes, please explain:
Vocational Schools Supplement
Page 4 of 8
© 2017 Philadelphia Consolidated Holding Corp.
05/2017
Clear Application
Print Application
5.
Number of employees using their own vehicles for school business (occasional or full-time use):
6.
For those employees who use their own vehicles for school business, either full-time or
occasionally, does the school require the employee to carry primary insurance?
Yes
No
If yes, what is the maximum limit the Applicant is requiring them to carry? $
7.
Does the Applicant have a full-time fleet manager?
Yes
No
If yes, please advise:
Number of years in current position:
Total number of years’ experience:
If no, who is responsible for fleet safety and maintenance?
8.
Does the school have a routine maintenance program for all vehicles?
Yes
No
9.
Are maintenance records kept for each vehicle?
Yes
No
10.
Does the Applicant’s organization utilize GPS fleet telematics devices?
Yes
No
If yes, please check off the fleet telematics being utilized:
Plug In
Hard Wired
Mobile Phone
Other:
11.
What percentage of the Applicant’s fleet is provided with these fleet telematics devices? %
12.
Does the school obtain Motor Vehicle Reports on ALL employees?
Yes
No
If yes, when?
At time of hire
Annually
Randomly (based on accidents or suspicions)
13.
Does the Applicant have a formal driving policy in place with MVR standards?
Yes
No
a.
Is driving policy communicated in writing to all employees?
Yes
No
Does the policy prohibit the use of cellphones / electronic messaging while driving?
Yes
No
b.
Is a signed acknowledgement form kept on file?
Yes
No
If yes, please attach a copy of signed acknowledgement.
c.
Does the Applicant have written guidelines defining an acceptable Motor Vehicle Record?
Yes
No
If yes, attach copy of guidelines.
14.
What action is taken if an “unacceptable” driver is identifiable?
15.
Does the Applicant perform accident investigations for each automobile accident?
Yes
No
16.
Does the Applicant allow any newly hired drivers to operate vehicles without going through a
company-specific documented driver training?
Yes
No
17.
Describe any ongoing training provided to drivers:
18.
Describe security regarding bus / vehicle storage:
Locked Garage
Fenced Lot
Lighting
Security Cameras
Security Personnel
Vehicle Locked When Unattended
Other:
19.
If the Applicant operates a Driving School:
a.
Do all vehicles have dual controls?
Yes
No
b.
Are all vehicles clearly marked as driver training vehicles?
Yes
No
c.
Please provide driver experience as follows:
Name:
Years Experience:
Name:
Years Experience:
Name:
Years Experience:
Name:
Years Experience:
Name:
Years Experience:
SECTION VI – MUSIC, DANCE & ART SCHOOLS
N/A
Do students / school do any traveling?
Yes
No
Are there any overnight trips? If yes, please explain:
Yes
No
Does the school do any performances off site?
Yes
No
If yes, how often:
Does the school ever invite the public onto the premises?
Yes
No
If yes, how often:
Please provide details of the events:
Does the school hold any events that charge a fee?
Yes
No
If yes, please explain:
Vocational Schools Supplement
Page 5 of 8
© 2017 Philadelphia Consolidated Holding Corp.
05/2017
Clear Application
Print Application
Does the school ever contract out their services?
Yes
No
If yes, please explain:
Is there a theater, auditorium, or stadium on premises?
Yes
No
If yes, please describe:
SECTION VII – DORMITORIES
N/A
How many dormitory buildings are owned by the Applicant’s institution:
What is the maximum number of stories:
Are the dormitories sprinklered in all areas?
Yes
No
Is each room equipped with hard-wired smoke detectors?
Yes
No
Are any of the following allowed in dorm rooms
Incense burners
Space heaters
Microwaves
Hot plates
Candles
Toasters or Toaster ovens
Does the dorm have a no smoking policy?
Yes
No
How many means of egress does each building have:
Are there emergency procedures in place including evacuation?
Yes
No
Is emergency lighting provided in the stairwells and hallways?
Yes
No
If dorms are coed, are boys and girls housed on the same floor?
Yes
No
Are staff members present in the dorms on all nights when students are?
Yes
No
Is there a scheduled security patrol for each building?
Yes
No
SECTION VIII – ABUSE & MOLESTATION
Does your 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
Does the 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
Are federal and state criminal background checks performed on
Staff?
Yes
No
Volunteers?
Yes
No
Do any independent contractors have access to students or perform operations where they will
be physically touching another person?
Yes
No
If yes, please explain:
Does the Applicant perform background checks on hired independent contractors?
Yes
No
Is there a new employee and volunteer orientation that includes training in abuse awareness?
Yes
No
Does the Applicant verify employment related references?
Yes
No
Does the Applicant conduct personal interviews?
Yes
No
Does the Applicant have written procedures dealing with sexual abuse?
Yes
No
If yes, please attach a copy.
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
Does the school have a Sexual Awareness Program for students?
Yes
No
Does the school have specific training for the faculty on identifying and reporting
incidents of sexual abuse and molestation?
Yes
No
Has the Applicant’s organization ever had an incident which resulted in an allegation of sexual
abuse? If yes, please describe the incident:
Yes
No
Was a claim made against the organization?
Yes
No
Was the case settled?
Yes
No
Was the case taken to trial?
Yes
No
How much money was paid in damages to the victim: $
13.
Regarding coverage for Abuse & Molestation, does your current insurance program
exclude coverage?
Yes
No
limit coverage?
Yes
No
If yes, please indicate limit of liability: $
Neither excludes nor limits coverage?
Yes
No
Vocational Schools Supplement
Page 6 of 8
© 2017 Philadelphia Consolidated Holding Corp.
05/2017
Clear Application
Print Application
WINTER WEATHER FREEZE-UP PROTECTION
1. Fire Protection and Testing
a. Is the building provided with an Automatic Fire Sprinkler System (AS)? Yes No N/A
i. If yes, approximately what percentage (%) of the building is sprinklered? %
ii. If yes, what type of sprinkler system is installed? Wet-Pipe Dry-Pipe Both
iii. If yes, when possible, is the sprinkler piping primarily run within conditioned
areas designed to ensure the temperature remains above the 45°F minimum
Yes No N/A
iv. If yes, is the testing & inspection by qualified sprinkler contractor completed
within past 12 months & includes a formal winterizatio
n review?
Yes
No
N/A
v. If yes, are the alarms tied to a 24 hour UL listed monitoring company?
Yes
No
N/A
2. Emergency Water Response (domestic and AS water lines)
a. Are water shutoff valves (domestic and AS water lines) marked and readily
accessible?
Yes
No
N/A
b. Are water shutoff valves exercised (closed and reopened) at least annually?
Yes
No
N/A
c. Is the staff qualified to respond and shut off the water main during normal business
hours and off hours?
Yes
No
N/A
3. Automatic Water Shutoff Devices
a. For domestic water lines, is there a water flow detection, notification and automatic
shutoff?
Yes
No
N/A
4. Unused/Vacant Spaces
a. Does Applicant have a formal process to turn off and drain domestic water lines for
these spaces?
Yes
No
N/A
5. Unheated Areas (attics, crawl spaces, exterior wall joists)
a. Are all domestic water lines located in areas heated to at least 45°F?
Yes
No
N/A
i. If no, please describe freeze prevention measures (e.g. temperature monitoring,
heat trace, full insulation):
This section must be completed by all risks that have a location in one of the following states: AR, CT, DC, DE,
GA, IL, IN, KY, ME, MD, MA, MI, MO, NH, NY, NJ, NC, OH, PA, RI, SC, TN, TX, VT, VA, WV, WI
temperature?
1. If no, please describe freeze prevention measures (
e.g. temperature
moni
toring, heat trace, full insulation on piping or roof):
6.
General Comments:
Vocational Schools Supplement
Page 7 of 8
© 2017 Philadelphia Consolidated Holding Corp.
05/2017
Print Application
Clear Application
FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief
and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true
and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes
prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the
quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,
MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN
EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, PA, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE
IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO
KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE
OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM
INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY
AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER
FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A
FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER
OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR
PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR
COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT
MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT,
FINES OR A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN PENNSYLVANIA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
_____________________________________________________________
SIGNATURE DATE
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)
Vocational Schools Supplement
Page 8 of 8
© 2017 Philadelphia Consolidated Holding Corp.
05/2017
Clear Application
Print Application
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Application - Vocational Schools Supplemental36-11171 Vocational Schools Supplemental Application

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

You have successfully completed this document.

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

This document has been signed by all parties.

Completed 2 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document