AMUSEMENT PARK APPLICATION
Pages 1-3 must be completed for all submissions
For Abuse and Molestation coverages, please complete page 3
If you provide Security, please complete pages 4-5
For Liquor Liability coverage, please complete pages 5-6
For Pyrotechnics exposure, please complete pages 7 - 8
For Hired and Non-Owned Auto coverage, please complete page 9
SUBMISSION REQUIREMENTS
1. Complete ACORD Property, Auto and Umbrella Liability if coverages requested
2. Currently valued insurance company loss runs for the current policy period plus 4 prior years
3. Web site information, brochures and photos
4. Facility diagram
5. Schedule of all rides and attractions
6. Ride Inspection forms
7. Copy of most current independent ride inspection report
8. Copy of employee training manual
9. Latest financial statement
10. Emergency evacuation plan
11. Certificates of Insurance from any sub-contractors / independent contractors, if any
GENERAL INFORMATION
1. Applicant name:
2. Name of park:
3. Mailing address:
Physical address:
4. Does the Applicant own or lease the park?
Own Lease
If leased, provide a copy of the leasing agreement.
5. Contact person: Telephone:
Contact e-mail address: Web address: www.
6. Business type: Corporation Partnershi
p Individual
Non-
Profit Governmental entity Other:
7. Year business was established? Number of years under present management:
FEIN:
8. List all Named Insureds and their interests:
Note: All First Named Insureds require common / majority ownership of all Named Insureds – If
not, please explain:
a.)
b.)
c.)
d.)
e.)
Explanation:
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9. Does the Applicant have a safety manager on premises at all times the park
is open? Yes No
If yes, provide name and contact information:
10. Does
the Applicant
have a formal
safety training pro
gram for employees? Yes No
1. Do all ride signs comply with manufacturer recommendations with regard to
age, height and exit requirements? Yes No
2. Does the Applicant or has the Applicant ever manufactured or retro-fitted any
amusements / attractions? Yes No
If yes, provide a list of all such attractions and the changes made.
3. Are rides inspected daily? Yes No
4. Is an inspection log maintained? Yes No
5. Are there periodic inspections required by state inspectors? Yes No
6. Are maintenance manuals for all rides kept on premises? Yes No
7. Is there a qualified maintenance staff on site? Yes No
8. Is there an on-site maintenance shop? Yes No
9. Is there adequate maintenance equipment on-site? Yes No
10. Are there rides where the operator controls the speed? Yes No
If yes, provide a list and operator training required.
11. Are operators trained to run more than one ride? If yes, what is the maximum
number?
Yes
No
12. Does the Applicant’s facility manufacture rides sold to the public? Yes No
Parking $
c.) Food and beverage $ Describe:
Souvenirs / Novelties $ Describe:
(explain any yes answers in Remarks)
1. Any medical facilities provided or any emplo
yed physicians / nurses?
2. Any storage, treating, discharging, applying, disposing or transportin
g
hazardous materials?
3. Any operations sold, acquired or discontinued in the last five (5) years?
4. Machinery, equipment or attractions rented to others?
5. Any watercraft docks (not bumper boats), floats on premises?
6. Is there a swimming pool on premises?
7. Are all swimming pools and spas compliant with Virginia Graeme Baker Pool
and Spa Safety Act? If no, provide time table and action plan:
8. Any special events scheduled throughout the year?
9. Any structural alterations contemplated?
10. Any demolition contemplated?
Remarks:
General Information:
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
1. Annual number of attendees: Operating season: to
Annual payroll: $ Number of employees:
a.) Admissions
b.)
d.) Beer and liquor sales $
e.)
GENERAL LIABILITY
Rides / Attractions
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Premises Exposure:
1. Does the Applicant have any of the following on premises:
Ice skating Yes No Roller skating Yes
No
Fire
works displays Yes
No
Buses or trams Yes No
Movie theater Yes No Full service restaurant Yes No
Race tracks / Go-karts Yes No Zoo (petting zoo) Yes No
Golf course Yes No Driving range Yes No
Athletic fields Yes No Museum Yes No
Day care facilities Yes No Hotel (complete hotel app.) Yes No
Cooking Facilities: Own Lease
1. Square footage of area if leased:
2. Does the Applicant have an automatic extinguishing system over deep fat
fryers, grills & stoves?
Yes
No
How often are hood / ducts cleaned?
By whom? Insured Sub-contractor
If by sub-contractor, how often are they serviced? Date last serviced?
3. Premises sprinklered? Yes No
Percent sprinklered? %
4. Central station fire alarm? Yes No
5. Central station burglar alarm? Yes No
6. Surveillance cameras? Yes No
7. Does the Applicant have Automated External Defibrillator(s) (AED)? Yes No
If yes, are staff members trained to use it? Yes No
8. Does the Applicant have backup emergency lighting and / or emergency
generators in the event of a power failure? Yes No
9. Does the Applicant have an emergency evacuation plan? (If yes, attach a
copy)
Yes No
Evacuation procedures and floor plans posted? Yes No
10. Are parking lots well lit? Yes No
Patrolled by security? Yes No
ABUSE AND MOLESTATION
1. Does the Applicant’s current insurance program include Abuse and
Molestation coverage? Yes No
2. 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
3. Does the Applicant verify employment referen
ces for employees and
volunteers?
Yes
No
4. Does the Applicant conduct personal interviews? Yes No
5. Are formal written procedures in plac
e for hirin
g? (If yes, attach a copy) Yes No
6. Is there a written supervision plan that monitors staff in day-to-day
relationships with clients, both on and off premises? (If yes, attach a copy)
Yes
No
7. Does the Applicant have a written crisis plan for dealing with employees,
volunteers, victims, parents, authorities and the media if you have an incident
of abuse? (If yes, attach a copy)
Yes
No
8. Have any incidents resulted in an allegation of sexual abuse? Yes No
If yes, was the case settled? Yes No
Was the case taken to trial? Yes No
Amount paid for damages to the victim: $
Does the Applicant’s state allow criminal background checks? Yes No
If yes, does the Applicant run criminal background checks prior to hire for:
Employees?
Yes No
Volunteers? Yes No
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SECURITY
(Complete only if security is the responsibility of the insured)
1. Who is primarily responsible (via contract) for liability coverage for security personnel?
Insured? Yes No
Municipality? Yes No
Sub-contractor? Yes No
2. Employed or sub-contracted security personnel? Employed Sub-contracted
“Employed” is defined as individuals being paid and supervised directly by the insured. “Contract”
is defined as the existence of a written contract with another entity for security services that has
separate insurance coverage and provided a certificate naming the Applicant as Additional Insured
with limits equal to or greater than the Applicant.
3. Number and payroll of employed security personnel:
Unarmed: # Payroll: $
Armed (not including off duty police officers): Number: Payroll: $
Off duty police officers: # Payroll: $
4. Sub-contracted security – annual cost of sub-contract: $
5. Total maximum hours per day permitted at this and all other places of employment:
Total maximum hours per week:
6. What are the staffing guidelines per number of patrons?
Are the guidelines determined by:
Ordinance? Yes No
Statute? Yes No
Industry standard? Yes No
Other: (describe)
7. Is there a procedure to immediately report all incidents to the facility
manager? If yes, describe:
Yes
No
8. Does the supervisor make personal contact with each security person at least
once during each shift? If yes, describe:
Yes
No
Please explain all no answers:
9 Is there a pre-employment screening procedure? If yes, describe. Yes No
10. Does the procedure include contacting previous employers over the previous
five (5) years?
Yes
No
11. Does the Applicant contact at least three (3) personal references? Yes No
12. Is completion of a minimum twenty (20) hours initial training program required
before deployment? Yes No
13. Who conducts the training and what are the trainer’s qualifications?
14. Is a minimum of ten (10) hours on-site training required? Yes No
15. Is a minimum of four (4 )hours of annual refresher or continuing education
training planned and conducted for each security employee? Yes No
16. Is each security person given a personal copy of the training / safety manual?
Yes No
If yes, has ea
ch security person given management a written
acknowledgment of the policies and contents?
Yes
No
NOTE: PLEASE INCLUDE A COPY OF THE MANUAL AND A SAMPLE OF THE WRITTEN
ACKNOWLEDGEMENT.
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ARMED SECURITY EMPLOYEES:
1. Are the security personnel in uniform? Yes No
If yes, describe the uniform:
2. Are the security personnel identified by anything other than a uniform? Yes No
If yes, describe
the identification & include
an example or photograph.
3. Are psychological screen profiles used? Yes No
If yes, specify type:
4. Are criminal background checks completed? Yes No
If yes, what agency is utilized?
5. Please indicate any equipment carried or routinely available to security personnel:
Flashlight: Type: Size: Construction:
Handcuffs First aid kit (including blood borne pathogen kit)
Nightstick: Is night stick police regulation or other?
Taser / Phaser Chemicals (M
ace, pepper gas)
Other:
Firearm Cal
iber:
.357 .38 .9mm Other:
Make: Colt
S & W Ruger
Cover Holster Type:
6. Is the ammunition: Standard Other:
7. Are firearm and ammunition approved and inspected by management or
security company?
Yes
No
8. Describe capabilities of each guard for constant communications with each
other, the supervisor, and management:
9. Are dogs used in your security operations? Yes No
If yes, provide the type of dog(s), number, and describe duties. Yes No
LIQUOR LIABILITY
1. Is liquor license in Applicant’s name? Yes No
If no, what is the name on the license and their relationship to the insured:
Liquor license number:
Class of license:
2. Is the liquor service sub-contracted to a third party? Yes No
If yes, provide limits of liability maintained by the sub-contractor: $
Is the Applicant listed as Additional Insured under sub-contractors liquor
liability coverage?
Yes
No
Is contingent liquor liability coverage requested by the Applicant? Yes No
3. Has the Applicant’s liquor license ever been revoked or suspended? Yes No
If yes, explain:
4. Has the Applicant incurred claims for liquor liability during the last three (3)
years? If yes, explain:
Yes
No
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5. Has any insurer cancelled or non-renewed coverage during the last three (3)
years? If yes, explain:
Yes
No
6. Has the Applicant ever been
fined by Alcoholic Bevera
ge Control
or other
governmental regulator? If yes, explain: Yes No
7. Type of beverages sold:
8. Are patrons allowed to carry alcoholic beverages onto the premises? Yes No
If yes, what type?
9. Does the Applicant exercise the right to search and seizure contraband
items?
Yes
No
If yes, how does the Applicant notify the public of this?
10. Does the Applicant maintain security personnel at entry check points? Yes No
If yes, what type?
11. Are the alcohol sales and consumption contained within one fixed site, or are
booths / stands located throughout the event site?
12. Number or servers used?
Are they professional servers? Explain: Yes No
Are they volunteer servers? Explain: Yes No
13. Do the servers receive any type of alcohol awareness training? Yes No
If yes, describe:
14. Median age of liquor customers:
21-25 25-30 30-40 40 and over
15. Are mino
rs allowed to enter the location where alcohol is being served? Yes No
If yes, how is underage consumption of alcohol prevented?
16. Explain
how ID’s are checked:
17. Are uniformed police officers present at the site of alcohol sales? Yes No
Are undercover police officers present? Yes No
Are private security officers present? Yes No
Average number of officers present at site:
18. Are rules and regulations clearly displayed for patrons viewing? Explain: Yes No
19. Is there a limit placed on the quantity of alcoholic beverages purchased at one
time? Explain: Yes No
20. Is the parking area patrolled to prevent intoxicated drivers from leaving the
premises? Explain: Yes No
21. Is there any type of designated driver program? Explain: Yes No
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PYROTECHNICS
(Complete if coverage is requested for Pyrotechnics Coverage (not including flashboxes))
1. Description of events:
2. Date(s) of event(s):
3. Who is the authority having jurisdiction over the use of pyrotechnics at your facility?
Local Fire Department State Fire Marshal Other: (please list)
4. What permit process must be followed prior to use of pyrotechnics at your facility?
5. Have you staged pyrotechnic displays before? Yes No
If yes, list any claims / losses that have occurred and the amount of loss:
Description
Date of Occurrence Amount of Loss
a) $
b) $
c) $
6. Who will be the pyrotechnics operator? Named Insured Contractor
Complete this section if the Pyrotechnics Operator is the Named Insured. Please note: This
coverage will exclude bodily injury liability to the fireworks shooter.
a) List names of people shooting and describe their experience.
Name: Experience:
b) Where are the pyrotechnics stored when not in use?
7. Does it meet federal / state storage regulation? Yes No
8. What quantity of pyrotechnic material is stored on site? (Number of shows,
number of pounds, etc.)
9. Describe the type of show and amount of pyrotechnics used in recurring
events:
10. Describe what fire prevention and suppression measures are taken to support
the pyrotechnic loading and firing process:
11. Does the Applicant secure proper pyrotechnic permits for each event? Yes No
12. Are the shooters listed above licensed for pyrotechnics? Yes No
Complete this section if the Pyrotechnics Operator is a Contractor.
a) Contractor Name:
b) Is there an agreement with the contractor? If yes, provide a copy of the
agreement.
Yes No
c) Please provide limits of liability provided by the Contractor. Note: Limits must be at least
$1,000,000 or greater. $
Please attach a copy of certificate of insurance including any additional insured listing.
d) Does the Applicant confirm that the contractor has secured the proper
pyrotechnic permits for each event?
Yes
No
e) Describe what fire prevention and suppression measures are taken to support
the pyrotechnic loading and firing process:
f) Does the Applicant allow tenant users (including temporary tenant users) to
conduct pyrotechnic displays either themselves or through a contractor?
Yes
No
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If yes, what steps are taken to ensure that the appropriate permits are
granted, appropriate fire safety codes ar
e met, and that insuranc
e has b
een
obtained from either the tenant or the tenant’s
contractor which lists you as an
additional insured?
If no, does the tenant lease / use agreement indicate that pyrotechnic displays
are not permitted?
Yes
No
g) Are events with pyrotechnics held: Indoor Outdoor
h) What type of pyrotechnics will be displayed (as defined in NFPA code 1126)?
Aerial Shells Airbursts Black Powder Comets
Concussion Effects Concussion Mortars Electric matches Flares
Flash Pots Flashpowe
r Gerbs Integrals Mortars
Mines Mortars Ro
ckets Saxons
Wheels Salutes Waterfall, Falls, Park Curtains
Other, please list:
OUTDOOR PYROTECHNICS
(only complete if outdoor pyrotechnic displays are staged)
1. Are the events in compliance with NFPA 1123 or 1126? (Code for fireworks
display)
Yes
No
2. Is there fencing to keep spectators away from restricted areas during the
fireworks shooting?
Yes
No
If yes, distance of spectators fencing from launch site:
Distance of spectator parking area from launch site:
Distance of closest building or structure from launch site:
3. Will there be firefighting equipment on site during the event? Yes No
If no firefighting equipment on site, give distance to nearest fire station:
4. Will the Applicant have an ambulance on site? Yes No
If no, what is the estimated response time of an ambulance?
If no, what is the distance to nearest medical facility?
INDOOR PYROTECHNICS
(Only complete if indoor pyrotechnic displays are staged)
1. Are the events in compliance with NFPA 1126? (Standard code for the use of
pyrotechnics before a proximate audience)?
Yes
No
2. Is the facility sprinklered? Yes No
3. What other form of fire fighting equipment is available at the facility?
4. Does the facility have an emergency evacuation plan? Yes No
If yes, how often is the staff drilled on emergency evacuation?
5. Number of accessible (not locked) emergency exits at the facility:
6. What steps are taken to inform patrons of the locations of all emergency
exits?
7. Maximum capacity of the facility:
8. Has the fire marshal approved the use of pyrotechnics at the facility? Yes No
If yes, as of what date:
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NOTE: If the Applicant has owned autos, the hired car and non-owned auto coverage should be
placed with the automobile carrier. Explain if an exception is required:
2. Does the Applicant allow employees to use their own personal vehicles for
business purposes? Yes No
If yes, how many employees use their own personal vehicles?
If yes, how often? Daily Weekly Monthly Other:
3. Does the Applicant obtain Motor Vehicle Reports? Yes No
If yes, how often? Annually Every other year Other:
4. Does the Applicant confirm that all employees who regularly use their cars for
business purposes carry minimum personal auto limits?
Yes
No
If yes, what minimum limits are required?
5. Please provide the approximate cost of hire for all hired or leased autos during
the course of the policy period:
6. Is hired auto physical damage required? Yes No
If yes, what is the maximum value of hired vehicle the Applicant would like
insured? $
NOTE: Physical Damage deductibles: $100 comprehensive / $1,000 collision
provided.
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HIRED & NON-OWNED AUTO
1. Does the Applicant have any owned automobiles? Yes No
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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 winterization re
view?
Yes
No
v. If yes, are the alarms tied to a 24 hour UL listed monitoring company?
Yes
No
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
b. Are water shutoff valves exercised (closed and reopened) at least annually?
Yes
No
c. Is the staff qualified to respond and shut off the water main during normal business
hours and off hours?
Yes
No
3. Automatic Water Shutoff Devices
a. For domestic water lines, is there a water flow detection, notification and automatic
shutoff?
Yes
No
4. Unused/Vacant Spaces
a. Does Applicant have a formal process to turn off and drain domestic water lines for
these spaces?
Yes
No
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
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
monitor
ing, heat trace, full insulation on piping or roof):
6.
General Comments:
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FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief
and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true
and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes
prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the
quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,
MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN
EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, PA, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE
IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO
KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE
OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM
INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY
AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER
FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A
FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER
OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR
PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR
COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT
MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT,
FINES OR A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN PENNSYLVANIA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
_____
________________________________________________________
SIGNATURE DATE
SE
CTION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
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CYBER SECURITY LIABILITY ENDORSEMENT SUPPLEMENTAL
QUESTIONNAIRE
Name of Applicant:
Address of Applicant:
City: State: Zip:
Website: www:
Nature of Operations:
1. Annual sales or revenue: $
2. Does the Applicant collect, store or otherwise handle any Personally Identifiable Information (PII)
belonging to customers, clients, or other third parties, other than employees?
If yes, please indicate the types of Personally Identifiable Information held (check all that apply):
Yes No
a. Social Security Numbers, Bank or Other Financial Account Details, Driver’s License or
other State Identification Numbers
b. Non-public Medical or Healthcare Data, including Protected Health Information (PHI)
c. Credit or Debit Card Information
3. a. During the last three (3) years, has anyone alleged that the Applicant was responsible for
damage to their computer system(s) arising out of the operation of the Applicant’s computer
system(s)?
Yes No
b. During the last three (3) years, has anyone made a demand, claim, complaint, or filed a
lawsuit again
st the Applicant
alleging invasion or interference of rights of privacy or the
inappropriate disclosure of Personally Identifiable Information (PII)?
Yes No
c. During the last three (3) years, has the Applicant been the subject of an investigation or
action by any regulatory or administrative agency for privacy-related violations?
Yes No
d. Is the Applicant aware of any circumstance that could reasonably be anticipated to result in a
claim being made against them for the coverage being applied for?
Yes No
PI-CYBE-APP (11/16)
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FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge
and belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this
Application) are true and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information
in this Application changes prior to the effective date of the policy, the Applicant will notify the Company of such changes and the
Company may modify or withdraw the quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
FRAUD NOTICE STATEMENTS
ANY PERSON
WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE
IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO
KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE
OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM
INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY
AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER
FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A
FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER
OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR
PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR
COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT
MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT,
FINES OR A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAM
E (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
____________________________________________________
SIGNATURE DATE
SECT
ION TO BE COMPLETED BY THE P
RODUCER/BROKER/AGENT
PRODUCER
AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
PI-CYBE-APP (11/16)
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