Fillable Application - Zipline Supplemental36-11559

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Application - Zipline Supplemental36-11559

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ZIPLINE SUPPLEMENTAL APPLICATION
SUBMISSION REQUIREMENTS
• Copy of most recent zipline course inspection
•
Copy of waiver of liability
SECTION I - APPLICANT’S INFORMATION
Applicant’s Name:
Mailing Address:
City:
State:
Zip:
Email address:
Telephone:
Risk Management’s Phone:
Risk Management Email:
SECTION II - GENERAL INFORMATION
1.
Location of Operation:
2.
Annual Gross Revenue: $
3.
Please list any associations that the Applicant is a member of:
4.
Number of years in business: years
SECTION III - COURSE INFORMATION
1.
Who originally built the course:
2.
When was the course built:
3.
Was the course built to ACCT or PRCA standards?
Yes
No
4.
Has the Applicant made any additions to the course since its original construction?
Yes
No
If yes, please provide details on a separate piece of paper including element name and
construction vendor name.
5.
Does the Applicant have its course inspected annually by a professional firm?
Yes
No
6.
Frequency of inspections:
Annual
Bi-Annual
Quarterly
Other:
7.
Date of last course inspection by professional firm:
8.
Number of ziplines:
Single Line:
Double Line:
9.
What is the length of each zipline:
10.
What is the maximum zipline height at the Applicant’s facility:
11.
What is the maximum speed of the fastest zipline: mph
12.
Does the Applicant maintain daily inspection logs for ziplines?
Yes
No
13.
Does the Applicant maintain daily inspection logs for all related equipment?
Yes
No
14.
What sort of braking system does the Applicant’s course use:
Primary:
Secondary:
15.
How do patrons access the zipline course?
Ladders
Steps
Ramps
Other:
16.
Does the Applicant have padding on its platforms and landing areas?
Yes
No
If yes, please explain:
Zipline Supplemental Application
Page 1 of 3
© 2016 Philadelphia Consolidated Holding Corp.
03/2016
Print Application
Clear Application
17.
How is the course kept restricted when not in use?
18.
Are any of the following terrains traversed:
Ravines
Gorges
Bodies of Water
19.
Does the Applicant provide any services after dark, including but not limited to, night ziplining and
overnight camping functions? Yes No
If yes, please describe:
20.
Are there any procedures in place for handling inclement weather conditions?
Yes
No
SECTION IV - PARTICIPANT INFORMATION
1.
Are participants harnessed prior to advancing to the top of the zipline platform?
Yes
No
2.
What type of harnesses does the Applicant use?
Waist Harness
Full Body
Both
3.
Minimum and Maximum weight limits:
Minimum:
Maximum:
4.
What age or height restrictions are in place:
5.
Are harnesses age or size appropriate?
Yes
No
Please explain:
6.
What helmet requirements are in place:
7.
Number of staff per tour:
Maximum number of guests per tour:
8.
What age restrictions are in place for the staff:
9.
Is there at least one certified staff member for every tour?
Yes
No
10.
What training certification is required for the staff:
SECTION V - TRANSPORTATION INFORMATION
1.
Does the Applicant provide transportation to / from its course?
Yes
No
Please explain:
2.
What types of vehicles are utilized to transport guests:
3.
Does the Applicant pick up guests from:
Hotels
Airports
Cruise Ships
Other:
4.
What is the maximum number of passengers allowed per vehicle:
SECTION VI - COURSE RENTAL INFORMATION
1.
Does the Applicant allow other organizations to use or rent its facilities?
Yes
No
If yes, please explain:
2.
Does the Applicant at any time allow its facility to be rented without its staff facilitating the course?
Yes
No
3.
Does the Applicant lease multiple courses throughout the year?
Yes
No
If yes, what is the Applicant’s selection criterion?
Zipline Supplemental Application
Page 2 of 3
© 2016 Philadelphia Consolidated Holding Corp.
03/2016
Clear Application
Print 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
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 FRAUDLENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT,
FINES OR A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE DIRECTOR)
____________________________________________________
SIGNATURE DATE
SECTION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
Zipline Supplemental Application
Page 3 of 3
© 2016 Philadelphia Consolidated Holding Corp.
03/2016
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