Fillable FLEA MARKETS/SWAP MEETS/BAZAARS GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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FLEA MARKETS/SWAP MEETS/BAZAARS GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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GLS-APP-24s (9-16) Page 1 of 7
Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
FLEA MARKETS/SWAP MEETS/BAZAARS GENERAL LIABILITY APPLICATION
Applicant’s Name:
Mailing Address:
Agency Name:
Agent:
Address:
E-mail:
Phone No.:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
Applicant is: Individual Corporation Partnership Joint Venture
Limited Liability Company Other (Specify):
Website Address:
E-mail Address: Phone Number:
Limits Of Liability and Deductible Requested:
General Aggregate
(other than Products/Completed Operations) $
Products and Completed Operations Aggregate $ Excluded
Personal and Advertising Injury (any one person or organization) $
Each Occurrence $
Damage to Premises Rented to You (any one premise) $
Medical Expense (any one person) $
Other Coverage, Restrictions, and/or Endorsements:
$
Deductible $
1. Describe all business operations conducted by applicant:
GLS-APP-24s (9-16) Page 2 of 7
2. Location, age and construction of all premises owned, rented, or controlled by applicant (attach schedule if
necessary):
3. Interest of applicant in such premises: Owner General lessee Tenant
Part occupied by the applicant: Entire Portion None
4. Number of years in business: ..................................................................................................................
5. Total number of employees: .....................................................................................................................
6. Description of Exposures:
Loc.
No.
Description of Exposures
Premium Basis:
Gross Sales
Premises—Operations (Give complete description including parking lot):
7. Does applicant have a parking area? ...................................................................................................... Yes No
If yes:
a. Square footage of all parking areas:
b. Are parking fees charged? .................................................................................................................... Yes
No
Annual gross receipts from parking: ..................................................................................................... $
c. Indicate type of surface: Gravel Black top Concrete
d. Is area checked regularly for potholes and uneven surfaces? ............................................................. Yes No
e. Is parking area lit? ................................................................................................................................. Yes No
8. Risk is: Indoor Outdoor Drive-in theater Other (describe):
a. If indoor, is there an emergency lighting system? ................................................................................ Yes No
b. How many exits?
c. How are cleanups of spills handled?
d. If outdoor, is there access to a phone for emergencies? ...................................................................... Yes No
e. Who is responsible for sanitary facilities?
9. Number of vendor spaces: .......................................................................................................................
Annual gross receipts from rental spaces: .................................................................................................. $
10. Is there an admission charge? ................................................................................................................. Yes
No
Annual gross receipts from admissions: ...................................................................................................... $
11. What is the average daily attendance?
12. How many days a week is risk open?
13. Is the risk open year round or seasonally?
If seasonally, what are the opening and closing dates?
1
4. Describe any use of premises when not open for business:
GLS-APP-24s (9-16) Page 3 of 7
15. Does applicant provide display booths? ................................................................................................ Yes No
If yes:
a. Describe:
b. Are materials fire resistant? .................................................................................................................. Yes No
16. Does applicant have any golf carts? ....................................................................................................... Yes No
If yes, how many? ........................................................................................................................................
17. Does aisle space meet local fire department regulations? ................................................................... Yes No
18. Are fire extinguishers kept on premises? ............................................................................................... Yes No
How often are they serviced?
19. Does applicant utilize a lease agreement? ............................................................................................. Yes No
If yes, provide a copy.
20. Does applicant subcontract work? .......................................................................................................... Yes No
If yes:
a. State type:
b. Are certificates of insurance required from all subcontractors? ............................................................ Yes No
c. Is applicant included as an additional insured on all subcontractors’ policies? .................................... Yes No
If no, what are the subcontracted job costs? ........................................................................................ $
21. Is applicant provided with a certificate of insurance from vendors? .................................................. Yes No
Is applicant included as an additional insured on all vendors’ policies? ..................................................... Yes No
22. Does applicant utilize security guards? .................................................................................................. Yes No
If yes:
a. Number of employed: Armed Guards: Unarmed Guards: Payroll: $
b. Number of contracted: Armed Guards: Unarmed Guards: Cost: ...... $
23. Is liquor allowed on premises? ................................................................................................................ Yes No
24. Does applicant sponsor any special events or promotions? ............................................................... Yes No
If yes, describe:
25. Do any vendors offer amusement rides? ................................................................................................ Yes No
If yes, describe:
26. Does applicant use any traffic control? .................................................................................................. Yes No
If yes, describe:
27. Does applicant sell food or merchandise or act as a vendor? ............................................................. Yes No
If yes, describe and provide applicable area and gross receipts:
28. Does applicant store petroleum products in underground tanks, L.P.G., flammable liquids,
ammunition or explosives on the premises? .........................................................................................
Yes No
If yes, type and quantity stored:
GLS-APP-24s (9-16) Page 4 of 7
29. Does applicant lend, lease or rent any equipment to others? .............................................................. Yes No
If yes, state the type of equipment involved and the gross receipts derived there from:
30. Does applicant have Workers’ Compensation coverage in force? ...................................................... Yes No
31. During the past three years, has any company ever canceled, nonrenewed, declined or refused
similar insurance to the applicant? (Not applicable in Missouri) ............................................................
Yes No
If yes, explain:
32. Does risk engage in the generation of power, other than emergency back-up power, for their
own use or sale to power companies?....................................................................................................
Yes No
If yes, describe:
33. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
34. Additional Insured Information:
Name Address Interest
35. Prior Carrier Information:
Year:
Year:
Carrier
Policy Number
Coverage
Total Premium
36. Loss History:
Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give
rise to claims for the prior five years.
Check if no losses in the last five years
Date of
Loss
Description of Loss
Amount
Paid
Amount
Reserved
Claim Status
(Open or
Closed)
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
GLS-APP-24s (9-16) Page 5 of 7
FRAUD WARNING: 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. (Not applicable in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY,
OH, OK, OR, RI, TN, VA, VT or WA.)
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation 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 policy holder or claimant for
the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: 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 addi-
tion, an insurer may deny insurance benefits if false information materially related to a claim was provided by the appli-
cant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insur-
er files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a fel-
ony of the third degree.
NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be pre-
sented 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 state-
ment 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 con-
ceals, 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.
NOTICE TO 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 sub-
ject to fines and confinement in prison.
NOTICE TO 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.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against
an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO 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 infor-
mation is guilty of a felony.
GLS-APP-24s (9-16) Page 6 of 7
NOTICE TO RHODE ISLAND 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.
GLS-APP-24s (9-16) Page 7 of 7
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents
a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties un-
der state law.
FRAUD WARNING (APPLICABLE IN 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. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
NEW YORK FRAUD WARNING: 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.
APPLICANT’S STATEMENT:
I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements
are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying. (Kan-
sas: This does not constitute a warranty.)
APPLICANT’S SIGNATURE: DATE:
CO-APPLICANT’S SIGNATURE: DATE:
PRODUCER’S SIGNATURE: DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IOWA LICENSED AGENT:
(Applicable in Iowa Only)
NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT:
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional
information as to the nature and scope of the report, if one is made, will be provided.
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FLEA MARKETSSWAP MEETSBAZAARS GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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