Fillable DOG TRIAL AND DOG TEST APPLICATION (Philadelphia Insurance Companies)

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DOG TRIAL AND DOG TEST APPLICATION (Philadelphia Insurance Companies)

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The DOG TRIAL AND DOG TEST APPLICATION (Philadelphia Insurance Companies) form is 4 pages long and contains:

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DOG TRIAL AND DOG TEST APPLICATION
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:
Business Form: Corporation Partnership Individual LLC Other:
Effective date:
Limit of Liability requested: $ 300,000 Occurrence
$ 500,000 Occurrence
$ 1,000,00
0 Occurrence
PRIOR CARRIER INFORMATION
Insurance Carrier Limits of Liability Premium
Last Year
Two Years Ago
Three Years Ago
ADDITIONAL INSUREDS, LANDLORDS REQUESTING ADDITIONAL INSURED STATUS
if necessary use another sheet of paper
Name Complete Address Interest
PRODUCING INSURANCE AGENT
AGENCY:
CONTACT:
ADDRESS:
TELEPHONE: FAX:
E-MAIL:
THIS IS AN APPLICATION FOR INSURANCE. THIS IS NOT A BINDER OF IN
SURANCE.
Named Insured:
Principal Contact:
Mailing Street Address:
Mailing City:
Location Street Address:
Location City:
Phone Number:
Website: www.
Risk Management Contact:
Risk Management Email:
Risk Management’s Phone:
Dog Trial and Dog Test Application
Page 1 of 4
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
Clear Application
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ACTIVITIES INFORMATION
Activities Conducted Number of Guides Number of Units
Club Members Members
Acreage-Leased Acres
Acreage-Owned Acres
Archery Range Stations
Range (Rifle & Pistol) – indoor Lanes
Range (Rifle & Pistol) – outdoor Lanes
Sporting Clay
Trap & Skeet
Big Game Hunting
Upland Bird Hunting
Waterfowl Hunting
Lakes or Ponds
Boats
Farming: Crops, Livestock $ Revenues
Clubhouse Square Feet
Lodging Rooms
Restaurant
Liquor Sales
Retail Store
Docks & Piers
ATV-guided
ATV-unguided
Youth Programs
Check all that apply to your operation:
For Profit Not-for-Profit Open to Public Private Membership
1. Do you require participants to sign a liability waiver? Yes No
2. How many years have you been operating? Years
3. If you are a new venture, how many years of prior experience? Years
4. Are any operations conducted outside of the United States? Yes No
5. Do you hire guides as sub-contractors? Yes No
If yes, for what activities?
If yes, do you obtain proof of insurance? Yes No
6. List safety procedures and / or attach safety guidelines:
SPECIAL EVENT / DOG TRIAL SECTION N/A
1. Special Events:
Provide number, revenue, and type of event(s): $
2.
Number of Average Maximum
Participants
Spectators
Volunteers
3. How many field trial events are held annually?
Number of : Hunt Tests
Training Sessions
Social Events
Meetings
4. What is the minimum age of a volunteer gunner – bird boy?
Years
5. Do you have a written safety program for hunt tests? Yes No
Dog Trial and Dog Test Application
Page 2 of 4
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
Clear Application
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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, describe:
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Dog Trial and Dog Test Application
Page 3 of 4
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
Clear Application
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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
SECTION TO BE C
OMPLETED 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)
Dog Trial and Dog Test Application
Page 4 of 4
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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DOG TRIAL AND DOG TEST APPLICATION (Philadelphia Insurance Companies)

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Completed 29 July 2020

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