Fillable FARM APPLICATION (Philadelphia Insurance Companies)

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FARM APPLICATION (Philadelphia Insurance Companies)

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FARM APPLICATION
REQUIREMENTS FOR SUBMISSION
Named Insured:
Address:
City:
State:
Zip:
Policy Term:
From:
To:
Business Type:
ATTENTION: Complete a separate description of each location to be covered with or without dwellings or
buildings. All owned or rented premises occupied or operated at inception must be described to be covered.
SECTION I – SCHEDULE OF LOCATIONS FOR INSURANCE
Prem
#
# of
Acres
Sec
#
Twp
#
Rnge
# Street Address, City County State Zip Code *Dwlgs *Bldgs PC
If more locations must be described, complete additional sheet.
*Indicates the number of Dwellings or separate sets of buildings on each land description.
LLC Joint Venture Other: Individual
Type of Farm: Livestock Fruit
Corporation
Hobby
Nuts
Partnership
Grain
Vegetables Vineyards
Dairy
Nursery Stock Other:
Page 1 of 16
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07/2020
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SECTION II – ADDITIONAL INTEREST
1.
Please check as applicable:
Mortgagee
Loss Payee
Contract Holder
Additional Insured
Lessor of Leased Equipment
2.
Name:
Loan Number:
3.
Address:
City:
State:
Zip:
4.
Applies to:
5.
Please check as applicable:
Mortgagee
Loss Payee
Contract Holder
Additional Insured
Lessor of Leased Equipment
6.
Name:
Loan Number:
7.
Address:
City:
State:
Zip:
8.
Applies to:
If additional lienholders needed, attach separate sheet.
SECTION III – FARM LIABILITY
LIMITS OF LIABILITY
$
COVERAGES
H.
Bodily Injury & Property Damage
I.
Personal & Advertising Injury
$
Basic Farm Liability
Blanketed Acres Yes No
Total Number of Acres
Additional dwellings on insured farm location.owned by named insured or spouse
Additional dwellings off insured farm location, owned by named insured or spouse and rented to others, but at
least partly owner-occupied
Additional dwellings off insured farm location, owned by named insured or spouse and rented to others with no
part owner-occupied
Additional dwellings on or off insured location, owned by a resident member of named insured’s household
$ each person
J.
Medical Payments to Others
Empl
oyees – Rated on a per capita basis (Not in CA, AZ)
Total Payroll = $
The following discloses as respects each type of insured farm employee the maximum number
employed at any one time during the policy period and as respects residence employees wherever
located, the number in excess of two, employed by the named insured or spouse or by any other
insured who is a resident of the named insured’s household. (ID & UT – premium is based on
payroll)
Insured Farm Employees
Number:
Full time residence employees, (not farm employees) in excess of two.
Number:
Liability Endorsements Requested:
Page 2 of 16
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SECTION IV – RECREATIONAL MOTOR VEHICLE COVERAGE
1.
Does the Applicant or members of the Applicant’s family own a snowmobile, motorcycle, all-terrain
vehicle, or comparable unit?
Yes
No
If yes, please complete the information below and indicate the physical damage or off-premises
liability coverage is desired.
Unit
#
Type
A-ATV
S-Snowmobile
M-Motorcycle
Year
Make
Model
Serial Number
Engine
Size
Cc’s
Value
Physical
Damage
Y/N
Off-
Premise
Liability
Y/N
Youthful
Operator
Y/N
Operator
Name
Date of Birth
Driver’s License Number
State
1.
2.
3.
4.
Please note licensed units are not eligible for coverage and appropriate application should be submitted.
SECTION V – COVERAGE A FARM DWELLING AND COVERAGE C HOUSEHOLD PERSONAL PROPERTY
Please complete the description of each dwelling to be insured under Coverage A or
containing household goods to be insured under Coverage C
COVERAGE A & C Deductible Options:
$500
$1,000
$2,500
Other: $
Please provide a completed dwelling replacement cost estimate for each dwelling to be insured.
Prem.
No.
Bldg./
Dwlg.
No.
Dwlg.
Yr. of
Const.
Sq. Ft.
of Area
(Ground
Floor)
Construction
F=Frame
M=Masonry
Dwelling
Condition
E=Excellent
G=Good
F=Fair
Roof Type
W=Wood
O=Other
Dwelling
Occupancy
O=Owner
T=Tenant
S=Seasonal
Define Heating
System & Fuel
Dwelling Protective
Devices
(Ex. Smoke detector;
dead bolts; local
burglar alarm; local
fire alarm
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Prem.
No.
Bldg./
Dwlg.
No.
Coverage A
Farm
Dwelling
Form
Coverage C
Unscheduled
Personal Property
(Household)
Form
Class
Codes
Year Systems Updated
(complete if older than
25 years)
B
a
s
I
c
B
r
o
a
d
S
p
e
c
B
a
s
I
c
B
r
o
a
d
S
p
e
c
$ $
Roof Elec
Plbg Heat
$ $
Roof Elec
Plbg Heat
$ $
Roof Elec
Plbg Heat
$ $
Roof Elec
Plbg Heat
$ $
Roof Elec
Plbg Heat
$ $
Roof Elec
Plbg
Heat
$ $
Roof Elec
Plbg Heat
$ $
Roof Elec
Plbg Heat
$ $
Roof Elec
Plbg Heat
$ $
Roof Elec
Plbg Heat
$ $
Roof Elec
Plbg Heat
$ $
Roof Elec
Plbg Heat
If more dwellings must be described, complete additional sheets.
Property Endorsements Requested:
Page 4 of 16
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COVERAGE G Deductible Options:
$500
$1,000
$2,500
Other: $
COVERAGE G – FARM BUILDINGS AND STRUCTURES
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
*Cause of Loss: BA = Basic; BR = Broad; SP = Special
COVERAGE E & F Deductible Options:
$500
$1,000
$2,500
Other: $
Prem.
No.
Bldg./
Dwlg.
No. Description Construction
Bldg.
Age
Roof
Size/
Capacity
Cont.
Found
Form
Class
Codes
Valuation
ACV, RC
Bldg.
Limit Type Age
B
A
B
R
S
P
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FARM PERSONAL PROPERTY – Please designate which is to apply :
Scheduled (E) or
Unscheduled (F)
Indicate items not owned 100% by insured, indicating the insurable interest beside item.
LIVESTOCK
Item
Units
Unit Value
Total
Item
Units
Unit Value
Total
Dairy Cows
$
$
Feeder Pigs
$
$
Dairy Calves
$
$
Boars
$
$
Stock Cows
$
$
Rams
$
$
Stock Calves
$
$
Ewes
$
$
Feeder Cattle
$
$
Lambs
$
$
Bulls
$
$
Goats
$
$
Horses
$
$
Chickens
(Turkeys
Excluded)
$
$
Sows
$
$
Total Livestock (1)
$
FARM PRODUCTS
Item
Units
Unit Value
Total
Hay & Straw (in the open)
$
$
Hay & Straw (in buildings)
$
$
Silage
$
$
Small Grain
$
$
Grain Under Seal
$
$
Corn
$
$
Soybeans
$
$
Commercial & Mixed Feeds
$
$
Total Farm Products (2)
$
FARM SUPPLIES
Item
Units
Unit Value
Total
Building Supplies
$
$
Fencing Supplies
$
$
Fertilizers
$
$
Gasoline, Oil & Grease
$
$
Herbicides & Pesticides
$
$
Medicines
$
$
Spare Parts
$
$
Small Hand & Power Tools
$
$
Total Farm Supplies (3)
$
MACHINERY
Item
Units
Unit Value
Total
Item
Units
Unit Value
Total
Tractor
$
$
Rotary Hoes
$
$
Tractor
$
$
Ensilage Blowers
$
$
Tractor
$
$
Cotton Picker-Oil
$
$
Combine
$
$
Cotton Picker-
Water
$
$
Corn Or Grain Heads
$
$
Grinders & Mixers
$
$
Hay Baler
$
$
Wagons & Trailers
(Not Licensed)
$
$
Grain Harvesters
Plows or Chisel
Plows
$
$
Sprayers
$
$
Discs
$
$
Self-Loading
Wagons
$
$
Harrows
$
$
Hayracks
$
$
Cultivators
$
$
Milking Machines
(not permanently
attached)
$
$
Corn Planters
$
$
Fertilizer Spreaders
$
$
$ $
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Portable Elevators or
Augers
$ $
Portable Irrigation
Equipment
(not eligible for
Coverage F)
$ $
Mowers $ $
Side Delivery Rakes $ $
Manure Spreader $ $ Self-Feeders-
3 Ton Limit $ $
Grain Driers
(Port. Only) $ $
Total Machinery (4)
$
GROUP TOTALS
Livestock 1 $
Farm Products 2 $
Farm Supplies 3 $
Machinery 4 $
Total Inventory
$
Insure for 100% of Total Inventory
Peak Season
Increased Limit
Start Date
End Date
$
$
$
$
$
$
$
$
$
$
$
$
SECTION VI – GENERAL INFORMATION
These questions must be answered and application sign by Applicant
(Add separate sheets as necessary)
1.
How long has the agent known the Applicant? Number of years:
2.
Date that the Agent personally inspected the property:
3.
Has any policy been cancelled or non-renewed in the past 5 years?
Yes
No
Please explain.
4.
Prior carrier:
Policy #:
Cancellation Date:
5.
During the last 10 years, has any Applicant been convicted of any degree of the crime of arson?
Yes
No
Please explain.
6.
Has the Applicant been involved in any lawsuits?
Yes
No
Please explain.
7.
Have any judgements or liens been rendered against the Applicant?
Yes
No
Please explain.
Item Units Unit Value Total Item Units Unit Value Total
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SECTION VII - OPERATIONS
1.
Applicant’s farming/ ranching experience in number of years:
2.
Is farming/ ranching the Applicant’s main source of income?
Yes
No
If no, please explain.
3.
Describe the farm/ ranch operations and any incidental business activities:
4.
Does the Applicant have a website pertaining to these operations?
Yes
No
Website address: www.
5.
Does the Applicant perform maintenance on equipment?
Yes
No
If yes, please indicate the types of repairs done, where performed and by whom:
6.
Is a formal safety program in existence?
Yes
No
Please explain.
7.
Are any of the Applicant’s operations insured with another company?
Yes
No
Please explain.
8.
Does the Applicant have any other business?
Yes
No
Please explain.
SECTION VIII - PREMISES
1.
Does the Applicant own a dog or other potentially dangerous pets?
Yes
No
a.
If yes, please provide number, breed and type of animal:
b.
Any history of dog bites or destruction of property?
Yes
No
Please explain.
2.
Is there a swimming pool on premises?
Yes
No
If yes, a Swimming Pool Questionnaire must be completed.
3.
Is there an airstrip on premises?
Yes
No
Please explain.
4.
Is there any unusual hazard such as (but not limited to) open dump pits, silage pits, sump holes,
ponds, lakes, or reservoirs?
Yes
No
Please explain.
5. Yes No Is there a trampoline on premise?
If yes, please complete the PHLY Trampoline Questionnaire.
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6.
Are any of the farm premises open to the public for any activities such as roadside stands, “u-pick”,
recreational, “rent-a-garden”, community supported agriculture, auctions, sales, shows, food or
beverage service, hay rides, fishing, kennels, animal boarding, or Christmas tree sales?
Yes
No
Please explain.
7.
Is any part of the farm/ ranch used or leased for organized recreational use?
Yes
No
Please explain.
8.
Are any portions of the farm/ ranch rented or leased or used by any individual, corporation, or
interest for other than farming/ ranching?
Yes
No
Please explain.
9.
Are any premises used for hunting purposes?
Yes
No
a.
Please explain.
b.
Is there a charge or fee?
Yes
No
Please explain.
c.
Are any items/ services provided?
Yes
No
Please explain.
10.
Does the Applicant maintain a non-farm office or private school in an insured building?
Yes
No
Please explain.
11.
Are any contract or service operations performed for others such as snow removal, tiling,
excavating, or ditching?
Yes
No
Please explain.
12.
Does the Applicant build, repair, or design machinery, equipment or systems for anyone at a charge
or fee?
Yes
No
Please explain.
13.
Does the Applicant handle any product such as seed, fertilizer, sprays, etc. for resale?
Yes
No
a.
Please explain.
b.
Receipts: $
14.
Are independent contractors hired to perform any farming operations?
Yes
No
Please explain.
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15.
Does the Applicant mix, process, slaughter, butcher or otherwise prepare for any “end-consumer”
his or any other grower’s product?
Yes
No
Please explain.
16.
Does the Applicant milk cows?
Yes
No
a.
Number of cows milked:
b.
Is there any processing of milk?
Yes
No
Please explain.
c.
Are there any sales of milk to the public?
Yes
No
Please explain.
SECTION IX - PROPERTY
1.
Is the entire premises occupied year round?
Yes
No
Please explain:
2.
Identify Fire District Name:
Miles to Fire Department:
3.
Is there a year-round water supply usable for fire protection?
Yes
No
Source:
Well
Pond/ Lake
Hydrant within 1,000 feet
Other:
Total Water Capacity:
4.
Are all residences and buildings located on a year-round accessible road?
Yes
No
Please explain.
5.
Are any locations prone to grass fires and/ or forest fires?
Yes
No
If yes, which ones?
6.
Are any of the Applicant’s residences or buildings located in heavily wooded areas?
Yes
No
If yes, which ones?
7.
Is the clearing from forest/ wooded areas greater than 500 feet?
Yes
No
If no, how many feet of defensible space do they have?
8.
Are any wood or coal fired stoves used in any buildings?
Yes
No
a.
Identify which buildings:
b.
Is the system checked and cleaned annually?
Yes
No
Attach completed Supplemental Heating Questionnaire and photo.
9
How far away from structures is gasoline or fuel stored?
10.
Is any property kept on a location(s) other than an insured location?
Yes
No
Where is it kept?
11.
What is the maximum value of equipment at any one location? $
12.
What is the radius of operations of equipment?
SECTION X - LIVESTOCK
1.
Are all areas adequately fenced, and are fences in a good state of repair?
Yes
No
a.
Please explain:
b.
Livestock premises are in:
Open Range Area
Closed Range Area
2.
Total number of livestock on all insured locations:
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3.
Does the Applicant own any horses?
Yes
No
Number:
4.
Are non-owned horses on any of Applicant’s premises?
Yes
No
Please explain.
5.
Does the Applicant board, race, breed, or rent horses?
Yes
No
Please explain. (Attach completed Equine Questionnaire)
SECTION XI - POLLUTION
1.
Does the Applicant apply anhydrous ammonia to his farm?
Yes
No
2.
Does the Applicant apply anhydrous ammonia to the farm of others?
Yes
No
a.
Please explain.
b.
Receipts: $
Attach a copy of the declarations page verifying coverage elsewhere.
3.
Does the Applicant apply herbicides or pesticides for others?
Yes
No
a.
Please explain.
b.
Receipts: $
c.
Does the Applicant require a certificate of application?
Yes
No
Attach a copy of the declarations page verifying coverage elsewhere.
4.
Has the Applicant ever had complaints regarding overspray, waste run-off, or other pollution
damages?
Yes
No
Please explain.
5.
Are herbicides and pesticides stored in a locked enclosure?
Yes
No
SECTION XII – MISCELLANEOUS
1.
Does the Applicant own a boat?
Yes
No
2.
Does the Applicant maintain any vacation or seasonal premises?
Yes
No
Please explain.
3.
Are any “hold harmless” or “indemnifying” agreements in effect?
Yes
No
Please explain.
4. Is any land held for real estate development or speculation? Yes No
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SECTION XIII – LOCATION DIAGRAMS
IMPORTANT: A DIAGRAM OF ALL BUILDINGS MUST BE COMPLETED, WHETHER INSURED OR NOT.
Pictures clear enough to portray the physical condition of each dwelling or building to be insured must
accompany the application.
Pictures must be identified by the item number on the Application along with the name of the building.
Pictures should be submitted with the application. Attach additional diagrams as necessary. The ACORD
405 may also be used as an alternative.
NORTH
SOUTH
LOCATION #1
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LOCATION #2
LOCATION #3
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SECTION XIV - PROPERTY AND LIABILITY LOSS INFORMATION *
Date of
Loss
Prior Carrier
Description of Loss
Amount paid
Reserve
$
$
$
$
$
$
$
$
$
$
SECTION XV - AUTOMOBILE
1.
Number of automobile operators with less than 5 years driving experience or under the age of 21:
a.
Which vehicles are assigned to these operators?
b.
Have any of those operators had major driving violations including DUI, racing, hit and run,
speeding in excess of 20 mph over the posted speed limit or manslaughter?
Yes
No
c.
Do any of those operators have more than one (1) moving violation or at fault accident?
Yes
No
d.
Has any youthful operators had their license suspended or revoked?
Yes
No
DISCLOSURE TO APPLICATION PURSUANT TO FAIR CREDIT REPORTING ACT.
You are hereby notified that as a part of our routine procedure in reviewing applications for insurance, an investigative
consumer report MAY be made. This inquiry includes information obtained through personal associates, financial
sources, friends, neighbors, or other with whom you are acquainted and typically includes information as to your
character, general reputation, personal characteristics and mode of living. You have the right to make a written request
within reasonable period of time for a complete and accurate disclosure of additional information concerning the nature
and scope of the investigation.
I hereby declare I have read the above questions and Disclosure Pursuant to the Fair Credit Reporting Act and that the
answers to the above questions are complete and truthful and request the Company to issue a policy of insurance in
reliance thereon.
I hereby represent that the values and amounts therein stated are true and correct as of this date. And it is agreed that if
this application approved I shall at all time maintain adequate insurance on all farm personal property owned by me to the
extent of 80% of its actual cash value at time of loss.
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.
2. Yes No Are all autos owned by and titled to the individual named insured?
If no, under what entity?
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REMARKS OR OTHER INSTRUCTIONS
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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)
Page 16 of 16
© 2020 Philadelphia Consolidated Holding Corp.
07/2020
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FARM APPLICATION (Philadelphia Insurance Companies)

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Completed 29 July 2020

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