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COVER-PRO APPLICATION ORGANIC CERTIFYING ENTITIES (Philadelphia Insurance Companies)

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Organic Certifying Entities Application Page 1 of 7 Ed. 05/2011
COVER-PRO
SM
APPLICATION
ORGANIC CERTIFYING ENTITIES
NOTICE: This professional liability coverage is provided on a claims-made basis; therefore, only claims which are
first made against you, and reported to the Company, during the policy term, any subsequent renewal of this policy
or any extended reporting period are covered, subject to policy provisions.
SUBMISSION REQUIREMENTS
• Applicant Firm’s statement of qualifications including resumes of all key (technical) personnel along
with any available marketing material or company brochures
• A copy of the Applicant Firm’s formalized standard client contract
• A copy of the outline from the Applicant Firm’s Quality Assurance / Quality Control (QA/QC) manual
GENERAL INFORMATION
1. Name of the Applicant Firm:
2. Applicant principal location
Address:
City: State: Zip Code:
Website: E-mail
address:
3. Date es
tablished: Telephone:
4. Describe the Applicant’s nature of business:
5. Is the Applicant controlled, owned, affiliated or associated with any other firm,
corporation or company? If yes, please provide an explanation:
Yes
No
6. Please list the address(es) of all branch offices and/or subsidiaries. Include a brief
description of their operations and indicate if coverage is desired for these offices.
Branch Office(s):
Subsidiary(ies):
7. During the past five (5) years has the name of the Firm been changed or has (have)
any other business(es) been acquired, merged into or consolidated with the Applicant
Firm? If yes, provide a complete explanation detailing any liabilities assumed.
Yes
No
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Organic Certifying Entities Application Page 2 of 7 Ed. 05/2011
8. Staffing
– Provide a breakdown of the Applicant’s staff into the following categories:
a. Principals, Partners or Officers:
b. Professionals (not included in a.):
c. Support staff (including part-time):
d. Part-time professionals (less than 20 hr/wk):
e. Inspectors:
f. Part-time inspectors (less than 20 hr/wk):
TOTAL:
9. Which of the following inspections does the Applicant perform?
Farm Crop Wild Crop Livestock and Dairy Processing
10. How many inspections does the Applicant average per year?
Farm and Ranch: Processing:
11. Is the Applicant a member of the International Organic Inspector’s Association
(IOIA)?
Yes
No
12. Has the Applicant, or any staff members, earned the IOIA accreditation (currently
accredited)?
Yes
No
13. What inspector training and education has the Applicant and/or any of its staff members completed in the
past three (3) years.
Course Training Sponsor Date
14. List the degrees earned by inspectors employed by the Applicant (excluding independent contractors):
Degree School Major Year
15. Dates of the Applicant’s current fiscal period: From: To:
PAST FISCAL
YEAR
CURRENT FISCAL YEAR ESTIMATE – NEXT YEAR
Total Gross Annual Revenue:
$ $ $
16. Provide the percentage of the Applicant’s gross annual revenue from the last fiscal period attributable to
the following:
Federal government: %
State, county or local government and agency thereof: %
Institutional (schools, hospitals, etc.): %
Lending Institutions: %
Manufacturing: %
Other (specify): %
17. Does the Applicant provide services for any clients in which a principal, partner,
officer or employee of your firm is also a principal, partner, officer, employee or a
more than three percent (3%) shareholder of said client?
Yes
No
If yes, please provide the following:
a. Client name:
b. Applicant’s relationship with the client:
c. Approximate annual gross revenue generated from this client: $
Clear Application
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Organic Certifying Entities Application Page 3 of 7 Ed. 05/2011
18. We
re more than fifty percent (50%) of the Applicant’s total gross annual billings for
any one year derived from a single client or contract?
Yes
No
If yes, provide the following:
a. Client name:
b. Services rendered:
c. How long do you expect this relationship to continue:
19. Describe the Applicant’s three (3) largest jobs or projects during the past three (3) years:
Client name:
Services Rendered:
Total gross billings: $
Client name:
Services Rendered:
Total gross billings: $
Client name:
Services Rendered:
Total gross billings: $
21. Does the Applicant secure a written contract or agreement for every project? Yes No
(Please attach a sample copy.)
If no, provide the percentage of your gross annual revenue where a written contract is
secured:
%
a. Does the Applicant’s contract contain any of the following? (check all that apply)
Hold harmless or indemnification clauses in your favor Guarantees or warranties
Hold harmless or indemnification clauses in your client’s favor Payment terms
A specific description of the services you will provide
22. Describe steps taken to minimize/manage business risks:
23. Has any policy or application for similar insurance on your behalf or on the behalf of
any of your principals, partners, officers, employees, or on behalf of any predecessors
in business ever been declined, canceled, or renewal refused? If yes, provide details:
Yes
No
24. Does the Applicant currently carry Commercial General Liability insurance? Yes No
25. Please provide the following information on your professional liability (E&O) insurance
for the past three (3) years:
Name of Insurer: Limit of Liability: $
Deductible: $ Premium: $ Policy Period: to
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Organic Certifying Entities Application Page 4 of 7 Ed. 05/2011
Name of Insurer: Limit of Liability: $
Deductible: $ Premium: $ Policy Period: to
Name of Insurer: Limit of Liability: $
Deductible: $ Premium: $ Policy Period: to
a. Retroactive date on current policy:
26. Have any claims, suits, or demands for arbitration been made against the Applicant,
its predecessor(s) or any past or present principal, partner, officer or employee within
the past five (5) years?
Yes
No
If yes, complete a Claim Supplement form for each incident.
27. Having inquired all principals, partners and officers, are you aware of any act, error,
omission, unresolved job dispute or any other circumstance that is or could be a basis
for a claim under the proposed insurance?
Yes
No
If yes, complete a Claim Supplement form for each incident.
28. Please indicate the number of claim supplemental forms attached to this application:
With regard to questions 26. and 27., it is understood and agreed that if any such claim, act, error,
omission, dispute or circumstance exists, then such claim and/or claims arising from such act, error,
omission, dispute or circumstance is excluded from coverage that may be provided under this proposed
insurance and, further, failure to disclose such claim, act, error, omission, dispute or circumstance may
result in the proposed insurance being void, and/or subject to rescission.
Coverage requested:
LIMIT OF LIABILITY:
$1,000,000 $3,000,000 $5,000,000
$2,000,000 $4,000,000
Clear Application
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Organic Certifying Entities Application Page 6 of 7 Ed. 05/2011
FRAUD NOTICE STATEMENTS
NOTICE TO APPLICANTS: “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 MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.”
RESIDENTS OF ALASKA APPLICANTS: “A PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE AN
INSURANCE COMPANY FILES A CLAIM CONTAINING FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY BE PROSECUTED UNDER
STATE LAW.”
RESIDENTS OF ARKANSAS APPLICANTS: “ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT
OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME
AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.”
RESIDENTS OF ARIZONA APPLICANTS: "FOR YOUR PROTECTION ARIZONA LAW REQUIRES THE FOLLOWING STATEMENT TO APPEAR
ON THIS FORM. ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS IS SUBJECT TO
CRIMINAL AND CIVIL PENALTIES."
RESIDENTS OF COLORADO APPLICANTS: “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.”
RESIDENTS OF DISTRICT OF COLUMBIA APPLICANTS: “WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO
AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR
FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS
PROVIDED BY THE APPLICANT.”
RESIDENTS OF FLORIDA RESIDENTS APPLICANTS: “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 OF THE THIRD DEGREE.”
RESIDENTS OF KANSAS APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR
OTHER PERSON 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 STATEMENT AS PART OF, OR IN SUPPORT OF, AN
APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT
PURSUANT TO AN INSURANCE POLICY 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, COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL
PENALTIES.”
RESIDENTS OF KENTUCKY APPLICANTS: “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.”
RESIDENTS OF LOUISIANA APPLICANTS: “ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT
OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME
AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.”
RESIDENTS OF MAINE APPLICANTS: “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.”
RESIDENTS OF MARYLAND APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM
FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY AND WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR
INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.”
RESIDENTS OF MINNESOTA APPLICANTS: “ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING
A FRAUD AGAINST ANY INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS
GUILTY OF INSURANCE FRAUD.”
RESIDENTS OF NEW JERSEY APPLICANTS: “ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN
APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.”
RESIDENTS OF NEW MEXICO APPLICANTS: “ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT
OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME
AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.”
Organic Certifying Entities Application Page 6 of 7 Ed. 05/2011
RESIDENTS OF NEW YORK APPLICANTS: “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 ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE
THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.”
RESIDENTS OF OHIO APPLICANTS: “ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING A
FRAUD AGAINST ANY INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS
GUILTY OF INSURANCE FRAUD.”
RESIDENTS OF OKLAHOMA APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY
INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING
INFORMATION IS GUILTY OF A FELONY.”
RESIDENTS OF OREGON APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD OR SOLICIT ANOTHER TO
DEFRAUD AN INSURER: (1) BY SUBMITTING AN APPLICATION, OR (2) BY FILING A CLAIM CONTAINING A FALSE STATEMENT AS TO ANY
MATERIAL FACT, MAY BE VIOLATING STATE LAW.”
RESIDENTS OF PENNSYLVANIA APPLICANTS: “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.”
RESIDENTS OF TENNESSEE APPLICANTS: “IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION
TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND
DENIAL OF INSURANCE BENEFITS.”
RESIDENTS OF TEXAS APPLICANTS: IF A LIFE, HEALTH AND ACCIDENT INSURER PROVIDES A CLAIM FORM FOR A PERSON TO USE TO
MAKE A CLAIM, THAT FORM MUST CONTAIN THE FOLLOWING STATEMENT OR A SUBSTANTIALLY SIMILAR STATEMENT: "ANY PERSON
WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE
SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON."
RESIDENTS OF VERMONT APPLICANTS: “ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICTION FOR
INSURANCE MAY BE GUILTY OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW.”
RESIDENTS OF VIRGINIA APPLICANTS: “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 AND
DENIAL OF INSURANCE BENEFITS.”
RESIDENTS OF WASHINGTON APPLICANTS: “IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSES OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE
IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS.”
RESIDENTS OF WEST VIRGINIA APPLICANTS: "ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR
PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A
CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON."
Name (Please Print/Type) Title
(MUST BE SIGNED BY THE PRINCIPAL, PARTNER OR
OFFICER
)
____________________________________________________
Signature Date
The above signed warrants that he/she is authorized and has the power to complete and execute this Application, including the
Warranty Statement on behalf of the Applicant and their respective Directors, Officers or other insured persons.
Produced By: (Section to be completed by Producer/Broker)
Producer Agency
Producer License Number Agency Taxpayer ID or SS Number
Address (Street, City, State, Zip)
Organic Certifying Entities Application Page 7 of 7 Ed. 05/2011
A
DDITIONAL INFORMATION
This page may be used to provide additional information to any question on this application. Please
identify the question number to which you are referring.
__________________________________________
Signature Date
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COVER-PRO APPLICATION ORGANIC CERTIFYING ENTITIES (Philadelphia Insurance Companies)

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