Fillable CONSULTING FORESTERS SPECIAL INSURANCE PROGRAM (Philadelphia Insurance Companies)

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CONSULTING FORESTERS SPECIAL INSURANCE PROGRAM (Philadelphia Insurance Companies)

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CONSULTING FORESTERS SPECIAL INSURANCE PROGRAM
SUBMISSION REQUIREMENTS
• All brochures describing any and all services; or website address.
• The liability waiver/hold harmless agreement you require your guests to sign, if applicable.
• Currently valued insurance company loss runs for the current policy period plus 3 prior years.
If unavailable, provide a no loss letter signed by the insured.
• ACORD forms for other lines requested (Property, Inland Marine, Crime, etc.)
GENERAL INFORMATION
State: Zip:
County: State: Zip:
Fax Number:
E-mail Address:
Corporation Partnership Individual LLC Other:
Limit of Liability Requested: (Please check one of each)
Limit of General Liability desired: $500,000 Occurrence $1,000,000 Occurrence
Limit of Errors & Omissions Liability desired:
$100,000 Occurrence $500,000 Occurrence
$250,000 Occurrence $1,000,000 Occurrence
PRIOR CARRIER INFORMATION
Insurance Carrier Limits of Liability Premium
Last Year $ $
Two Years Ago $ $
Three Years Ago $ $
ADDITIONAL INSUREDS, if necessary use another sheet of paper
Name Complete Address Interest
PRODUCING INSURANCE AGENT
AGENT:
CONTACT:
ADDRESS:
TELEPHONE: FAX:
E-MAIL:
THIS IS AN APPLICATION FOR INSURANCE. THIS IS NOT A BINDER OF INSURANCE.
Named Insured:
Principal Contact:
Mailing Street Address:
Mailing City:
Location Street Address:
Location City:
Phone Number:
Proposed Effective Date:
Website: www.
Risk Management Contact:
Risk Management Email:
Business Form:
Risk Management’s Phone:
Consulting Foresters Special
Insurance Program
Page 1 of 4
© 2018 Philadelphia Consolidated Holding Corp.
07/2018
Clear Application
Print Application
OPERATIONS INFORMATION
1. Are you a member of the Association of Consulting Foresters of America
(ACF) or currently under review for membership?
Yes
No
2. Are you a full-time consulting forester? Yes No
3. Where did you receive your forestry degree?
4. Number of years in business? Years
If less than 3 years, describe previous experience.
5. Please provide a brief description of your business:
6. Is your company a subsidiary of or owned by another company? Yes No
If yes, please explain:
7. Do you have one client who generates over 60% of your revenue? Yes No
If yes, please explain:
BUSINESS ACTIVITIES
Staffing Information
Number of
People
Last Year’s
Actual Payroll
This Year’s
Estimated Payroll
Foresters Employed $ $
Forest Technicians Employed $ $
Other Labor / Employees
(excluding clerical)
$ $
Briefly describe other labor:
Briefly describe any other professional employees:
Activities Conducted
Last Year’s Actual
This Year’s
Estimated
Controlled Burning Yes No # Burns
# Acres # Burns # Acres
Chemical Application Yes No # Jobs
# Acres # Jobs
# Acres
Logging Operations Yes No % of Revenue % of Revenue
Road Construction Operations Yes No % of Revenue % of Revenue
If yes to any activity above, please describe:
Do you use other consultants as independent contractors? Yes No
If yes, describe what operations they perform:
If yes, are they insured? (attach their proof of insurance) Yes No
Consulting Foresters Special
Insurance Program
Page 2 of 4
© 2018 Philadelphia Consolidated Holding Corp.
07/2018
Clear Application
Print Application
REVENUES
1.
Over the last three (3) years, approximately what percentage of your gross revenues come
from the following:
Land a
ppraisal / valuation: %
Timber appraisal / valuation, including timber volume and economic studi
es: %
Purcha
sing of
land
:
%
Urban forestry: %
Environmental impact studies: %
Computer Services – Forest application:
%
Litigation, expert witness: %
Taxation counseling: %
Management of clients property and forest resources, including timber sales, timber
preparation and administra
tion, controll
ed burns, regeneration and silviculture, fire
control, wildfire, and chemical application:
%
What percentage of your management revenue is attributed to controlled burns: %
What percentage of your management revenue is attributed to chemical application: %
Mapping – including aerial
:
%
Logging / Hauling operations including sub-contracted operatio
ns (Certificates of
Insurance must be provided PRIOR TO
QUOTING for logging / hauling ope
rations for all
sub-contractors showing our insured as an additional insured on their policies.)
%
Other – Please specify:
%
2. In the next twelve months, do you expect any of these percentages to fluctuate
up or down more than 20%? If yes, please explain:
Yes
No
LOSS HISTORY
Date Description of Incident Amount Paid / Reserved
$
$
$
$
1. Do you have knowledge of any incident which may lead to a claim? Yes No
If yes, please describe:
Consulting Foresters Special
Insurance Program
Page 3 of 4
© 2018 Philadelphia Consolidated Holding Corp.
07/2018
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
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)
Consulting Foresters Special
Insurance Program
Page 4 of 4
© 2018 Philadelphia Consolidated Holding Corp.
07/2018
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CONSULTING FORESTERS SPECIAL INSURANCE PROGRAM (Philadelphia Insurance Companies)

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Completed 29 July 2020

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