Fillable CHILD CARE CENTER SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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CHILD CARE CENTER SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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CHILD CARE CENTER SUPPLEMENTAL APPLICATION
SUBMISSION REQUIREMENTS
• ACORD Applications
• Resume of Director of new venture
•
For Business Income ALS, complete page 5
• Currently valued insurance company loss runs for
the current policy period plus three (3) prior years
GENERAL INFORMATION
Applicant:
Location address:
E-mail:
Web address:
Risk Management Contact:
RM Email:
Years in business:
This child care center is located in which type of building?
Church
School
Private Home (NOT Eligible)
Other (describe):
Hours of operation:
1.
Is the child care center licensed?
Yes
No
2.
If licensing is NOT state required, why is the center exempt:
3.
Has a license to operate ever been denied, suspended or revoked?
Yes
No
If yes, please explain thoroughly on a separate document.
BUILDING SPECIFICS
1. Does the child care center exit directly to the outside? Yes No
To ground level? Yes No
2. Do the bathroom doors lock? Yes No
Can they be unlocked from the outside? Yes No
3. Does the child care center have smoke detectors? Yes No
If yes, are they: battery operated or hard-wired to the building
4. Are doors equipped with pinch guards to prevent fingers from getting caught? Yes No
5. Has a lead abatement been performed since 1978? Yes No
6. Have asbestos materials been: not present removed protected to prevent flaking
STAFF AND CHILDREN
1. Based on the maximum number of children enrolled on your busiest day, what is your actual breakdown of
total staff to total number of children by age group (excluding director)
AGE GROUP # OF CHILDREN AVERAGE DAILY ATTENDANCE # OF TEACHERS
Infants, ages 0 – 1
Toddlers, ages 1 – 2
Toddlers, ages 2 – 3
Preschoolers, ages 3 – 5
School Age Children
2. Are children allowed to use the restroom without a teacher present? Yes No
If yes, how many children are allowed in the restroom at one time:
3. Is a minimum of one staff member certified in first aid present at all times? Yes No
4.
OPTIONAL: If male staff, provide details of
a) Length of employment:
b) Any one-on-one activities? Yes No
c) Duties performed, including age groups:
4. Yes No Is the Applicant’s organization more than 25% owned by a private equity fund structure?
If yes, provide name of private equity firm:
Child Care Center
Supplemental Application
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03/2020
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CORPORAL PUNISHMENT
1.
What is the Applicant’s policy on corporal punishment?
Allowed
Prohibited
If allowed, please submit a copy of the written policy concerning the use of corporal punishment.
2.
Have there ever been any claims for corporal punishment?
Yes
No
HEALTH AND SAFETY
1.
Does the Applicant provide sick child or drop in services? If yes, please explain.
Yes
No
2.
How many children require special care and treatment? Please explain.
3.
Indicate if a file containing the following information is maintained on each child.
a.
Are there Immunization records of the children being updated annually?
Yes
No
b.
Are there records for each child indicating unusual conditions the child has?
Yes
No
c.
Are signed releases for emergency medical treatment/dispensing of medication
obtained from parents?
Yes
No
d.
Written instructions from child’s physician for dispensing of child’s medication?
Yes
No
SEXUAL ABUSE
1. Does the Applicant’s employment process (for employees, volunteers, and independent
contractors) 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. During new staff orientation, does the Applicant discuss child/sexual abuse, how to
recognize the signs and what to do if a child reports that someone molested him or her? Yes No
3.
Yes No
Yes No
Yes No
Does the Applicant perform national criminal background investigations and is a sex
offender register check completed on all:
Employees?
Volunteers?
Independent contractors?
If no, please explain:
4. How long has the Applicant been performing these checks: years
5. For how many years does the Applicant keep these records on file after employee leaves: years
6. Does the Applicant verify employment-related references? Yes No
7. Does the Applicant conduct a personal interview? Yes No
8. Does the Applicant’s supervision plan monitor staff in day-to-day relationships with children
both on and off premises? Yes No
9. How is the staff monitored? Video Windows Other:
10. Yes No Are there operable surveillance cameras in all classrooms and inside play areas?
If yes, is the video saved? Yes No If yes, for how long:
11.
Yes No
Does the Applicant contract with any vendors who have contact with any children in your
care?
If yes, please explain:
12.
Yes No
Are there any other circumstances where adults, who are not the Applicant’s employees,
have access to any child in your care?
If yes, please explain:
13. Yes No Does the Applicant have written procedures for dealing with sexual abuse?
MANDATORY: Provide a copy of procedures.
14. Yes No Has the Applicant ever had an incident which resulted in an allegation of sexual abuse?
If yes, please complete:
a) Was a claim made against the organization? Yes No
b) Is that individual still employed with your organization? Yes No
c) What changes were made to prevent recurrence?
Child Care Center
Supplemental Application
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03/2020
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4.
Is food properly covered, stored and served in according to government requirements?
Yes
No
5.
Does the Applicant have an accident / health policy?
Yes
No
Is coverage mandatory for all children?
Yes
No
Provide carrier limits of liability:
Policy term:
6.
Does the Applicant require evidence of personal medical insurance for all children?
Yes
No
7.
Does the Applicant have a written emergency evacuation plan in effect?
Yes
No
8.
Please describe the Applicant’s daily check in and release procedures:
9.
Are any pets or animals kept on premises?
Yes
No
Describe animals, caging, and type of interaction:
SECURITY
1.
Are any of the Applicant’s locations protected by security personnel?
2.
If yes, are the security personnel
a.
Sub-contracted?
b.
Employed?
c.
Other (please explain):
3.
Does the Applicant’s state permit open and/or concealed carry of weapons on your
premises?
4.
Does the Applicant have a written policy permitting open and/or concealed carry of
firearms on any premises for which you are requesting insurance coverage?
5.
If the Applicant permits open and/or concealed carry of firearms on any premises for
which you are requesting insurance coverage, please identify who you grant this
permission to:
a.
Staff?
b.
Guests?
6.
If the Applicant does not permit open and/or concealed carry of firearms on any
premises for which you are requesting insurance coverage, do all locations have signage
which conspicuously identifies the building as a Gun Free Zone?
AUTOMOBILE N/A
1.
Does the Applicant provide regular transportation for children?
Yes
No
If yes: Maximum distance:
miles
Minimum age:
2.
Is a walk-around vehicle checklist used prior to transporting children?
Yes
No
3.
Are all drivers put through specialized drivers training in transporting children?
Yes
No
4.
How are children accounted for getting on and off the bus:
5.
How often do employees or volunteers drive their own vehicles for transporting children:
6.
Does the Applicant require evidence that they have their own auto insurance?
Yes
No
If yes, limit required: $
7.
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:
8.
What percentage of the Applicant’s fleet is provided with these fleet telematics devices:
%
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
9. Yes No Does the Applicant have a formal driving policy in place with MVR standards?
If yes:
a. I
s driving policy communicated in writing to all employees? Yes No
b. Yes No Is a signed acknowledgement form kept on file?
If yes, please provide a copy of signed acknowledgement.
c. Do driving standards include the following:
Yes No
Yes No
No major violations including DUI, racing, hit and run, speeding in excess of
20 mph over posted speed limit, manslaughter?
No more than 2 moving violations within past 3 years?
No more than 1 at fault accident within past 3 years? Yes No
10. How often does the Applicant check MVR reports?
11. Describe any ongoing training provided to drivers:
Child Care Center
Supplemental Application
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12.
Does the Applicant allow employees to drive personal vehicles for company purposes?
Yes
No
If yes:
a.
Are the driving policy and standards for these drivers the same as in questions
9 & 10?
Yes
No
b.
Does the Applicant require these employees to have adequate personal insurance
limits?
Yes
No
SPECIAL ACTIVITES
Play Area
1.
Is the area fenced?
Yes
No
2.
Are any trampolines and inflatables present?
Yes
No
3.
Describe playground surface:
Field Trips and Off Premises Travel
1.
How many field trips are taken per year:
2.
Describe the field trips:
3.
Are parental waivers obtained?
Yes
No
4.
Minimum age taken on trips:
5.
How are children transported:
Child Care Vehicle
Parent
Other:
Activities
1.
Are special classes provided? (check all that apply)
Gymnastics
Dance
Karate
Tumbling
Birthday Parties - # of children:
Other:
Please explain:
2.
Are special classes taught by an independent contractor on your premises?
Yes
No
3.
Does the Applicant request/maintain Certificates of Insurance from all sub-contractors?
Yes
No
4.
Does the Applicant have any operations other than child care?
Yes
No
If yes, please explain:
Summer Camp
1.
Number of children (other than children in the childcare program):
Ages:
2.
Number of weeks attending:
3.
Number of additional staff:
4.
Describe outings away from camp location:
Swimming Pools
1.
Does the Applicant now use or plan in the future to use swimming facilities?
Yes
No
2.
Is the pool you use, or plan on using, located: on Applicant’s premises at a separate location
3.
Are all swimming pools and spas compliant with Virginia Graeme Baker Pool and Spa
Safety Act?
Yes
No
If no, provide timetable and action plan:
Answer the following questions for pool to be used:
4.
Are water depths marked?
Yes
No
5.
What is the maximum depth:
feet
6.
Is there a diving board? Yes No Is there a slide into the pool?
Yes
No
7.
Is the pool area completely fenced?
Yes
No
8.
Are lifeguards present? Yes No Is there a self-locking gate?
Yes
No
9.
Ratio of staff to child when at pools: to
10.
Minimum age of children allowed in the water:
11.
Minimum age of children in the water:
12.
Walking surface in good shape and non-slip?
Yes
No
Child Care Center
Supplemental Application
Page 4 of 9
© 2020 Philadelphia Consolidated Holding Corp.
03/2020
BUSINESS INCOME ACTUAL LOSS SUSTAINED
A.
Business Incomes exposures from the following sources
ACTUAL REVENUE FOR PAST 12 MONTHS
1.
Total Annual Tuitions:
$
2.
Ordinary Payroll Expense*:
$
3.
Continuing Expenses:
$
B.
Total B/I Exposure for 12 months:
$
C.
Less Cost of
1.
If excluding or limiting “Ordinary Payroll”, deduct all
“Ordinary Payroll” Expenses. (See note below.) If not
excluding or limiting “Ordinary Payroll”, leave blank:
$
2.
Other Non-continuing Expenses:(describe)
$
D.
Total Deductions: (Items 1 – 2)
$
E.
Total Business Income Value: (B – D)
$
Complete only if extra expense is requested**
F.
Method 1: 25% of Total Revenue:
$
G.
Method 2: Calculation by Category**
1.
Rental for temporary Child Care location:
$
2.
Moving Expenses:
$
3.
Overtime / Other Extra Expense:
$
4.
Other:
$
H.
Total Gross Extra Expense:
$
Deduct expenses discontinued at original location because of
loss:
($ )
I.
Net Extra Expense: (From line F or Line H)
$
J.
TOTAL INSURABLE BUSINESS
INCOME / EXTRA EXPENSE: (E + I) (Agreed Amount)
$
*
Ordinary Payroll expenses include payroll, employee benefits if directly related to payroll, FICA and
Medicare payments, union dues, and Workers Compensation premiums. Some points to consider in
deciding whether to exclude or limit Ordinary Payroll (ie: other than officers, executives, managers and
employees under contract):
1.
Would you lay off all your other employees in the event of a short interruption?
Yes
No
Describe:
2.
Could you get them back when operations are restored or would they have gone
elsewhere?
Yes
No
Describe:
**
Extra Expense Coverage provides additional coverage in the event of a covered loss for necessary
expenses sustained during the period of restoration that you would not have incurred if there had been no
direct physical loss or damage to property. For example, if it becomes necessary for you to rent another
building at another unnamed location in order to continue your operations during the period of recovery.
Two methodologies are being offered to determine your Extra Expense exposure. Which methodology you
use is up to you.
Child Care Center
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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 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
monitoring, heat trace, full insulatio
n on piping or roof):
6.
General Comments:
Child Care Center
Supplemental Application
Page 6 of 9
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03/2020
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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, 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 VERMONT: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY
OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW.
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
SEC
TION 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)
Child Care Center
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.
CYBER SECURITY LIABILITY ENDORSEMENT – SUPPLEMENTAL
QUESTIONNAIRE
Name of Applicant:
Address of Applicant:
City: State: Zip:
Website: www:
Nature of Operations:
1. Annual sales or revenue: $
2. Does the Applicant collect, store or otherwise handle any Personally Identifiable Information (PII)
belonging to customers, clients, or other third parties, other than employees?
If yes, please indicate the types of Personally Identifiable Information held (check all that apply):
Yes No
a. Social Security Numbers, Bank or Other Financial Account Details, Driver’s License or
other State Identification Numbers
b. Non-public Medical or Healthcare Data, including Protected Health Information (PHI)
c. Credit or Debit Card Information
3. a. During the last three (3) years, has anyone alleged that the Applicant was responsible for
damage to their computer system(s) arising out of the operation of the Applicant’s computer
system(s)?
Yes No
b. During the last three (3) years, has anyone made a demand, claim, complaint, or filed a
lawsuit against
the Applicant alleg
ing invasion or interference of rights of privacy or the
inappropriate disclosure of Personally Identifiable Information (PII)?
Yes No
c. During the last three (3) years, has the Applicant been the subject of an investigation or
action by any regulatory or administrative agency for privacy-related violations?
Yes No
d. Is the Applicant aware of any circumstance that could reasonably be anticipated to result in a
claim being made against them for the coverage being applied for?
Yes No
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
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, 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 VERMONT: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY
OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW.
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.
NA
ME (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)
PI-CYBE-APP (11/16)
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CHILD CARE CENTER SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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Completed 29 July 2020

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