Fillable COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

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COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

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The COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers) form is 3 pages long and contains:

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  • 48 check-boxes
  • 22 other fields

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File type: PDF

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C‐APP024‐0815 Page1of3
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION - HUNT CLUBS AND HUNTING PRESERVES - SUPPLEMENTAL APPLICATION
ACORD Application also required - Check all applicable checkboxes below
General Agent:
Date:
Insured:
Insured Mailing Address:
Insured’s Web Address:
Insured Contact Name:
Phone Number:
PROHIBITED (check all that apply to your operations)
Alcohol, IF provided by insured
Alligator trapping
ATV’s, Motorcycles, Saddle animals or Snowmobiles, UNLESS used by insured only
Firearms, IF loaning, leasing, renting or selling, and/or there are gunsmithing or reloading exposures
Night time hunting
Operations on Tribal Lands
Territory includes locations outside of the United States
Tree blinds, tree stands or tower stands provided by insured
YEARS IN BUSINESS / EXPERIENCE
_____ Years in business as the ‘Named Insured’ indicated on this application
_____ Years’ experience in the operations indicated on this application - Attach resumes if available
Has applicant had an insurance policy cancelled or non-renewed in past 3 years? If yes, explain.
(Missouri Applicants - Do not answer this question)
Applicant in receivership
Bankruptcy (Chapter 7, 11 or 13) has been filed in past 5 years
LOSS HISTORY
Three years of loss history information provided on ACORD application or attached to this application
OPERATIONS / EXPOSURES / CONTROLS
Applicant charges customers a fee for the privilege of hunting
Applicant does not charge a fee - hunting is for guests and family members only
Applicant is a club - club members rent land from others for the purpose of hunting
Applicant is ‘other’ (describe):
C‐APP024‐0815 Page2of3
HUNT CLUBS AND HUNTING PRESERVES - SUPPLEMENTAL APPLICATION
OPERATIONS / EXPOSURES (continued)
Ages of participants include those under the age of 16:
Adult is required to accompany anyone under age 16
Confirm anyone under 16 has a certificate of completion of approved hunter safety course
Boat exposures exist. Number of boats: _______ Types of boats: ______________________________
Boat motors (if any) are 60 HP or less
Length is 26 feet in length or less
Life jackets are required for all riders
Safety gear provided on all boats
Whitewater exposures are level 1 and 2 only, no level 3, 4 or 5
Insured obtains all required permits and/or permissions if accessing public lands or private property
Land owned by applicant used for hunting and/or as a preserve. Number of acres: _______
Fenced
Lakes(s) Number of acres: _______
Signs posted advising no trespassing
Land owned by third parties is used for hunting purposes and permission is always obtained (whether a fee for
access is paid by the applicant to the third party or not)
SUBCONTRACTORS / INDEPENDENT CONTRACTORS
Uninsured subcontractors are not acceptable
Risk Transfer – Subcontractors: (check if applicable)
Additional Insured – Status granted to you on the subcontractor’s policy
Certificates of Insurance - Always obtained from a subcontractor prior to any work being done for you
Limits of Liability - Subcontractors are required to carry limits equal or above your own
CLUB MEMBERS
Number of memberships (if any): _______
Club member contracts (if any) include a ‘Release of Liability’ and ‘Waiver’
RECEIPTS
Receipts from Hunting Operations (if any)
$
Receipts from Memberships (if any)
$
COVERAGE OPTIONS - LIABILITY (check if you would like an optional quote on any of the following)
Employee Benefit Liability – U058
Employment Practices Liability Insurance – U817 (Not available in AR, LA, MT, NM, NY, VT)
High Limits General Liability
Identity Recovery – i.e. Identity Theft – U651
Medical Expense Limit of $10,000 rather than $5,000
Stop Gap Liability – U066
COVERAGE OPTIONS - PROPERTY (check if you would like an optional quote on any of the following)
Building Ordinance or Law (Increased Cost of Construction) – U750
Equipment Breakdown – U522 & U523
Property Coverage Enhancement:
Bronze – U777C Silver – U777B or Gold – U777A
Signs (Outdoor) – CP1440
Water Back Up and Sump Overflow – U548
C‐APP024‐0815 Page3of3
HUNT CLUBS AND HUNTING PRESERVES - SUPPLEMENTAL APPLICATION
GENERAL FRAUD STATEMENT (Not applicable in all states.)
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, may be committing a fraudulent insurance act, and may be subject to
a civil penalty or fine.
The undersigned is an authorized representative of the applicant and certifies that reasonable inquiry has been made to
questions on this application. He/She certifies:
The answers are true, correct and complete to the best of his/her knowledge.
They agree to the Privacy and Fraud provisions found in the ACORD-125 (Commercial Insurance Application)
and understand those provisions also apply to this supplemental application.
SIGN AND DATE
PRODUCER’S SIGNATURE DATE
APPLICANT’S PRINTED NAME DATE
APPLICANT’S SIGNATURE DATE
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COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

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Completed 17 July 2021

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