Fillable FISHING AND HUNTING LODGE APPLICATION-FLORIDA (Philadelphia Insurance Companies)

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FISHING AND HUNTING LODGE APPLICATION-FLORIDA (Philadelphia Insurance Companies)

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FISHING AND HUNTING LODGE APPLICATION-FLORIDA
SUBMISSION REQUIREMENTS
• All brochures describing any and all services; or website address above.
• 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
1. Do you operate any other businesses from this location? Yes No
(List information below for each business, use a separate sheet to list information if necessary)
If yes, type of entity:
Corporation Partnership Individual LLC Other:
Description of other business:
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
AGENCY:
CONTACT:
ADDRESS:
TELEPHONE: FAX:
E-MAIL:
THIS IS AN APPLICATION FOR INSURANCE. THIS IS NOT A BINDER OF INSURANCE.
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State: Zip:
County: State: Zip:
Fax Number:
Risk Management’s Phone:
Partnership Individual LLC Other:
Named Insured:
Principal Contact:
Mailing Street Address:
Mailing City:
Location Street Address:
Location City:
Phone Number:
Website: www.
Risk Management Contact:
Risk Management Email:
Business Form: Corporation
Effective Date:
Limit of Liability requested: $300,000 Occurrence
$500,000 Occurrence
$ 1,000,000 Occurrence
Fishing and Hunting Lodge - Florida
Page 1 of 10
© 2018 Philadelphia Consolidated Holding Corp.
07/2018
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PROPERTY SECTION
N/A
1.
Is your location within 50 miles of the Gulf of Mexico or the Atlantic Ocean?
Yes
No
2.
What is the Fire Protection Class of your location?
3.
Distance to fire station?
Miles
4.
Is the responding fire department
staffed or
volunteer?
5.
Distant to fire hydrant?
Feet
6.
Are there other fire control water sources available?
Pool
Pond / Lake
Water Tank
Other:
7.
Is your location prone to grass fires and/or forest fires?
Yes
No
8.
Are there buildings at your facility with limited access due to forest, terrain or
season?
Yes
No
9.
Are your buildings located in heavily wooded areas?
Yes
No
10.
Is the clearing from forest / wooded areas greater than 150 feet?
Yes
No
11.
Is your business operational year round?
Yes
No
If no, provide the number of months you are operational?
Months
12.
Are your buildings occupied year round?
Yes
No
13.
If no, is there a caretaker on site?
Yes
No or contracted?
Yes
No
14.
If no, are buildings winterized?
Yes
No
Building Information
1.
Are there smoke alarms in all corridors and bedrooms?
Yes
No
2.
What type of smoke alarms are installed?
Battery
Hardwired
3.
Is there a CO alarm installed?
Yes
No
4.
Do any buildings have cooking facilities?
Yes
No
If yes, list building numbers:
5.
Do any buildings have wood burning fireplaces and/or woodstoves?
Yes
No
If yes, list building numbers:
If yes, are the chimneys and flues cleaned annually?
Yes
No
6.
Do any buildings have any ACTIVE knob & tube and/or aluminum wiring?
Yes
No
If yes, list building numbers:
7.
Do you have power generating equipment?
Yes
No
If yes, is it 100% for emergency use only?
Yes
No
List the size of each unit (in HP and KW):
LODGING SECTION (Guest Quarters)
N/A
1.
Total number of units for guest rental:
2.
Number of RV spaces / tent sites:
3.
Maximum guest capacity is:
ACTIVITIES INFORMATION
Actual Total Receipts for Prior 12 Months:
$
Estimated Total Receipts for Next 12 Months:
$
Activities Conducted
# of Guides
# of Units
User Days
Revenues
Guided Fishing
$
Hiking/Backpacking
$
Hunting
$
Lodging/Cabin Rentals
$
Horseback Riding
$
Hay, Sleigh or Wagon Rides
$
Shooting Range – Rifle or Pistol
$
Bike Rentals
$
Mountain Bike Riding
$
Boating $
Sea Kayak Tours/Rentals $
Water skiing $
Fishing and Hunting Lodge - Florida
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Activities Conducted # of Guides # of Units User Da
ys Revenues
Jet Skis or Wave Runners $
River Tubing $
Whitewater Rafting $
Cross Country Skiing $
Dog Sled Tours $
Downhill Skiing $
ATV’s $
Snowmobiles $
Paintball $
Climbing Wall $
Rock Climbing $
Youth Camps or Programs $
Club Members
Acreage – Leased Acres
Acreage – Owned
Archery Range Stations
Range (Rifle & Pistol) – indoor Lanes
Range (Rifle & Pistol) – outdoor Lanes
Sporting Clay Lanes
Trap & Skeet
Big Game Hunting
Upland Bird Hunting
Waterfowl Hunting
Lakes or Ponds
Boats
Farming: Crops, Livestock
Clubhouse
Lodging
Restaurant
Liquor Sales $
Retail Store $
Docks and Piers
ATV – guided
ATV – unguided
Youth Programs
Other(describe): $
Check all that apply to your operation:
For Profit Not-for-Profit Open to Public Private Membership
OPERATIONS INFORMATION
1. Do you require your guests to sign a liability waiver? Yes No
2. How many years have you been in business? 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:
KITCHEN OPERATIONS N/A
1. Do you have an automatic extinguishing system over the cooking surface? Yes No
Sq.Ft.
Members
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
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2. Do you have automatic fuel shut-off to stove? Yes No
3. Is there a maintenance contract to clean your duct system? Yes No
4. Do you have one or more fire extinguishers? Yes No
5. Do you have any deep fat fryers? Yes No
6. Is there a restaurant, bar or lounge on the premises? Yes No
If yes, is it open to the general public? Yes No
7. What are your annual liquor sales? $
8. What are your annual restaurant sales, not including liquor? $
9. Of restaurant & liquor sales, what percentage is from people NOT lodging at the resort? %
10. What is the restaurant seating capacity?
SERVICE OPERATIONS N/A
1. Do you host any of these events? Annual Revenues
Weddings Yes No $
Conferences Yes No $
Special Events, describe: Yes No $
2. Do you provide the catering at these functions? Yes No
3. Do you provide the liquor at these functions? Yes No
If no, do you collect certificates from the caterers that work on your premise? Yes No
If you are requesting Liquor Liability you must complete the Liquor Liability Supplemental Application
RETAIL OPERATIONS N/A
1. Do you have retail operations for any of the following?
General Store Pro Shop Restaurant
Liquor Store Gift Shop Fuel Sales
2. What are your total gross sales from retail operations? $
POOL AND SWIMMING AREAS N/A
1. How many of each: Pools Lakes Other:
Are all swimming pools and spas compliant with Virginia Graeme Baker Pool and
Spa Safety Act? If no, provide time table and action plan:
Yes
No
2. Are your swimming facilities open to the general public? Yes No
3. Fenced? Yes No
4. Diving board? Yes No
5. Locking gate? Yes No
6. Is the depth of pool marked? Yes No
7. Are life rings or buoys provided? Yes No
8. Lifeguard on duty? Yes No
9. Pool rules posted? Yes No
10. Is there signage “No life guard, swim at your own risk, no diving”? Yes No
11. Do you have a water trampoline? Yes No
12. Do you have a waterslide? Yes No
If yes, what is the length & height of slide? Length: / Height:
DOCK INFORMATION
1. Number of docks?
2. Number of boat slips?
Complete the questions below only if property coverage is requested.
3. Construction: Frame Metal Floating Fixed Roofed Age:
If roofed, has proper engineering for wind / snow loads been assessed? Yes No
4. Does the water around your dock freeze? Yes No
If yes, what date on average?
5. Are the docks removed? Yes No
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WATERCRAFT LIABILITY SECTION N/A
Boat Schedule (if necessary use another sheet of paper)
Year Make & Model Length HP OB/IB/IO # Pass Guided
Yes No
Yes No
Yes No
Yes No
WATERCRAFT GENERAL INFORMATION N/A
1. What type of operation do you have?
Boat Rentals Fishing Trips Tube or Canoe Rentals Hunting
Other(describe):
2. On what bodies of water does use take place?
Rivers Lakes Ocean Bays/Inlets
3. If rivers, what classes are boated:
Class I Class II Class III Class IV Class V
4. Are life vests (PFD’s) required? Yes No
5. Are life vests (PFD’s) provided? Yes No
CANOE, KAYAK AND/OR RIVER TUBING INFORMATION N/A
Boat Type Maximum Number Used Average Number Used
Canoes
Kayaks
Tubes
1. What percent of your operations are unguided %
2. Number of guides?
HUNTING SECTION N/A
1. What percentage of your hunting operations are unguided? %
2. What type of game is being hunted?
Elk Deer Exotics Bear Turkey Upland Birds
Hogs Alligators Waterfowl Other:
3. Are tree stands used? Yes No
Do you use any of the following to transport hunters? If yes, how many?
ATVs:
Horses:
Snowmobiles:
Boats:
Other unlicensed vehicles:
EXPOSURE INFORMATION
Use of helmets on ATVs is mandatory frequent rare nonexistent N/A
Use of muzzleloaders is frequent rare nonexistent prohibited
Use of pistols is frequent rare nonexistent prohibited
Use of modified weapons is frequent rare nonexistent prohibited
Tree stand use is frequent rare nonexistent
Tree stand safety harness use is mandatory frequent rare nonexistent
frequent rare nonexistent Heavy equipment use is
(Tractors, bulldozers, etc.)
ATV, Hunting Buggy, Argo use is frequent rare nonexistent
Snowmobile use is frequent rare nonexistent
Sponsored youth events are frequent rare nonexistent
Members sign liability waivers mandatory frequent rare nonexistent N/A
Fishing and Hunting Lodge - Florida
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Guests sign liability waivers mandatory frequent rare nonexistent N/A
Clients sign liability waivers mandatory frequent rare nonexistent N/A
SHOOTING RANGE SECTION N/A
1. Is a rangemaster / supervisor on premise during shooting hours? Yes No
2. What is the minimum age of an unsupervised shooter? Years Old
3. Is the premise secured and locked when not operating? Yes No
4. Are range rules and safety guidelines posted in a conspicuous manner? Yes No
5. What is the maximum distance of ranges? Yards
6. What type and kind of backstop or berm is used?
Describe:
EQUINE SECTION N/A
Ride Information
1. Total number of horses available for guest riding:
2. Maximum number of horses in use for guest riding at any one time:
3. Average number of horses in use for guest riding at any one time:
4. What is the youngest rider you will allow on a horse? Years Old
5. Do you offer the use of helmets? Yes No
6. Do you ever allow double riding? Yes No
7. What percentage of your guest ride: Western Saddle: % vs. English Saddle: %
8. What percentage of your horse operations are: Unguided: % vs. Guided: %
9. What is the maximum guide to guest ratio? Guides to Guests
10. Do you operate pony rides? Yes No
If yes: Trail Ride Riding Ring Hand Led
11. What is the youngest rider you will allow on a pony? Years Old
12. Do you require guest to complete a physical fitness information form prior to
riding?
Yes
No
13. Do you pre-screen guest riders and determine ability prior to riding? Yes No
14. Do guides carry with them any communication device
(2-way radio, cell phone, etc.?) Yes No
15. Do you conduct a pre-ride safety briefing with guests? Yes No
16. Do you provide a written safety manual of procedures to all staff members? Yes No
17. Do you ever participate in parades or community celebrations with your horses? Yes No
18. Lists reasons why you would decline a person from riding (health, age, weight,
alcohol, general, pregnancy):
ACCOUNT INFORMATION
1. Do you board horses for a fee? Yes No
If yes, how many?
2. Do you teach or allow your guests to participate in:
Dressage Inoculations Barrel Racing Horse Jumping
Horse Racing Team Penning Hay Rides Roping Cattle
Cattle Drives Sleigh Rides Branding Cattle Handling Livestock
Buckboard/ Buggy Rides
3. Are guests allowed to handle, rope or brand livestock? Yes No
4. If you conduct cattle drives, what is the number of:
Wranglers to Riders Maximum Duration: Maximum Distance:
5. If your ranch conducts a Rodeo / Gymkana, describe what activities your guests can participate in:
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Fishing and Hunting Lodge - Florida
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GUIDE INFORMATION
Name Age Years Experience First Aid Qualifications
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:
Page 1 of 1
Title:
© 2014 Philadelphia Consolidated Holding Corp.
Fishing and Hunting Lodge - Florida
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FRAUD NOTICE STATEMENTS
APPLICABLE IN FLORIDA : 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).
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
.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR
EXECUTIVE DIRECTOR)
____________________________________________________
SIGNATURE DATE
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)
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CYBER SECURITY LIABILITY ENDORSEMENT – SUPPLEMENTAL
QUESTIONNAIRE
Name of Applicant:
Address of Applicant:
City: State: Zip:
Website: www:
Nature of Operations:
1. Annual sales or revenue: $
2. Does the Applicant collect, store or otherwise handle any Personally Identifiable Information (PII)
belonging to customers, clients, or other third parties, other than employees?
If yes, please indicate the types of Personally Identifiable Information held (check all that apply):
Yes No
a. Social Security Numbers, Bank or Other Financial Account Details, Driver’s License or
other State Identification Numbers
b. Non-public Medical or Healthcare Data, including Protected Health Information (PHI)
c. Credit or Debit Card Information
3. a. During the last three (3) years, has anyone alleged that the Applicant was responsible for
damage to their computer system(s) arising out of the operation of the Applicant’s computer
system(s)?
Yes No
b. During the last three (3) years, has anyone made a demand, claim, complaint, or filed a
lawsuit against t
he Applicant alleging
invasion or interference of rights of privacy or the
inappropriate disclosure of Personally Identifiable Information (PII)?
Yes No
c. During the last three (3) years, has the Applicant been the subject of an investigation or
action by any regulatory or administrative agency for privacy-related violations?
Yes No
d. Is the Applicant aware of any circumstance that could reasonably be anticipated to result in a
claim being made against them for the coverage being applied for?
Yes No
PI-CYBE-APP (11/16)
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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 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)
PI-CYBE-APP (11/16)
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FISHING AND HUNTING LODGE APPLICATION-FLORIDA (Philadelphia Insurance Companies)

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Completed 29 July 2020

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