Fillable Flexi Plus Five New App36-8642

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Flexi Plus Five New App36-8642

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FLEXI PLUS FIVE APPLICATION
NOT-FOR-PROFIT ORGA
NIZATION DIRECTORS
AND OFFICERS LIABILITY INSURANCE
EMPLOYMENT PRACTICES LIABILITY INSURANCE
FIDUCIARY LIABILITY INSURANCE
WORKPLACE VIOLENCE COVERAGE
INTERNET LIABILITY INSURANCE
THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY
PLEASE READ YOUR POLICY CAREFULLY
Instructions:
• Whenever used in this Application the term Applicant shall mean the Parent Organization and its wholly-
owned/controlled subsidiaries.
• The Applicant is required
to complete Sections 1, 2, and 7.
• The Applicant should complete other applicable Section(s) for which coverag
e is desired. (See char
t
below)
Check Coverage Desired Section Requested Limit Requested Retention
General Information
1 N/A N/A
Directors & Officers
2 $ $
Employment Practices
3 $ $
Fiduciary Liability
4 $ $
Workplace Violence
5 $ $
Internet Liability
6 $ $
General Summary
7 N/A N/A
SECTION 1 – GENERAL INFORMATION
(All Applicants must
complete this section)
1. Name of Parent Organization: ________________________________________________________________
2. Address:
________________________________________________________________________________________
Telephone: ____________________ Internet Address: www.
_______________________________
3.
Date Established: __________________________ State of Incorporation: ___________________________
4. Standard Industrial Classification (SIC) #: ______________
4a. Federal Employer Identification (FEIN) #: xxxxxxxxxxxxxxxxxxx_____________________
5. Please describe
the nature of the App
licant’s operations: ___________________________________
_______
_______________________________________________________________________________________
_______________________________________________________________________________________
_____________________________________
___________________________________________________
_______________________________________________________________________________________
6. Does the Applicant hav
e a tax-exempt status under the U.S. Internal Revenue Code? Yes No If no,
prov
ide an explanation.
_______________________________________________________________________________________
_______________________________________________________________________________________
7. The Officer of the Applicant designated to receive any and all notices from the Underwriter or their authorized
representative concerning this insurance is:
_______________________________
PIIC-NPD-NEW APP (09/06)
Page 1 of 9
Name Title E-mail Address
Print Application
Clear Application
PIIC-NPD-NEW APP (09/06) Page 2 of 9
8. Number of Members: __________________________ Number of Chapters: ________________________
Please attach details for all “YES” answers to questions 8 – 12.
9. Doe
s the Applicant publish any magazines, periodicals
or newsletters? Yes No
10. Is
the Applicant involv
ed in prod
uct research, product development, testing and/or certification? Yes No
11. Does
the Applican
t set standards for the qualification and performance and/or certify its member
s?
Yes No
12. Doe
s the Applicant engage in any disciplinary actions as a result of peer review ac
tivities? Yes No
13. Does the Applican
t administer or sponsor any insurance programs for its members?
Yes No
FINANCIAL INFORMATION
CURRENT FISCAL YEAR PREVIOUS FISCAL YEAR
TOTAL ASSETS: $_________________________
$__________________________
NET ASSETS / FUND BALANCE: $______________
___________ $______________
____________
ANNUAL REVENUE: $_________________________ $__________________________
NET REVENUE $_________________________
$__________________________
Please attach the most recent annual financial audit or 990 form.
SECTION 2 – DIRECTORS AND OFFI
CERS
(All Applicants must
complete this section)
1. Directors and Officers Liability Insurance has been
continuously in force since: __________________________
2. Provide a list of all direct
and indirect subsidi
aries or any other entity or organization the Applicant controls:
Percent the Applicant DateCre
ated/ For Profit /
Name/Type of Business Owns/Controls
Acquired Non-Profit
_____
Example:
ABC Foundation, Inc/ Charitable Children’s Foundation 100% 01/01/2000 Non-Profit
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
____
___________________________________________________________
____________________________
Additional entities listed by attachment
3. Has the Applicant o
r any person proposed for coverage herein been the subject of, or involved in, any of the
following in the past five (5) years?
If yes, please attach details.
Anti-trust, copyright or patent
litigation?
Yes No
Any disciplin
ar
y action by any regulator
y agency or association?
Yes No
Any action where a license was revoked or suspended? Y
es No
Any administrative proceeding charging violation of a federal o
r state law or regul
ation? Yes No
Any other criminal actions?
Yes No
It is agreed that
with re
spect to Question #3, if su
ch circumstances exist, any claim arising from such
circumstances are excluded from the proposed insurance.
Print Application
Clear Application
PIIC-NPD-NEW APP (09/06) Page 3 of 9
4. In the past twenty-four (24) months or the next twelve (12) months, has the Applicant been, or anticipate being
involved in any of the following?
Mergers, acquisitions or consoli
dation with another entity? If yes, please attach details. Yes No
Changes in the board of directors or senior management (other than death or retirement)? Yes No If yes,
please attach details.
5. Does the Applicant direct or request any individual to serve a
s director, office
r, governor or trustee
of any other
entity?
Yes No If yes, please attach details.
SECTION 3 – EMPLOYMENT PRACTICES
(Comple
te this section only
if Employment Practices Liability coverage is desired.)
1. Employment Practices Liability Insurance has been continu
ously in force since: _________________________
_
2. Please provide the following employee count information:
U.S. based employees/volunteers: Curre
ntly One Year Ago Two Years Ago
Full
Time employees: ______ ___________
_____________
Part Time employees: _____
_____ _______
Temporary employees: _____ _____
Volunteers: _____ _____
Non U.S. based employees/volunteers: __________ __________ ___________
TOTAL SUM OF ABOVE: ___________ ____
__ _______
3. How many employees have been terminated or de
moted in the past twelve (12) months?
Voluntary: __________ Involuntary: ____________ Laid Off: ____________ Demoted: ____________
4. Is any reduction of empl
oyees or
change of statu
s anticipated in the next year?
Voluntary: _________ Involuntary:
____________ Layoffs: ____________ Demotions: ___________
5. Does the Ap
plicant have an employment handbook?
Yes No
6. Doe
s the Applicant use an
employment application for every potential employee?
Yes No
7. Does the Applicant have an “At Will” provision in the employment application or handbook? Yes No
8. Has the Applicant implemented an anti-sexual ha
rassment policy? Yes
No
9. Has the Applicant implemented an anti-discrimination policy? Yes No
10. Does the Applicant use ou
tside employment counsel for employment advise? Yes No
SECTION 4 – FIDUCIARY LIABILITY
(Complete this section only
if Fiduciary liability coverage is desired.)
1. Fiduciary Liability Insurance has been continuously in force since: ______________________________
2. List all plans for which coverage is requested (use attachment if necessary):
Year Assets/
Plan Name Established Contributions Type* Participants Administrator
Example:
The ABC Children Corp 401K Plan 2000 $1,000,00 2 75 self
a)
b)
c)
d)
* 1=Employee Welfare Benefit Plan (as defined by ERISA), 2
= Defined Contribution Plan (as defined by
ERISA), 3= Defined Benefit Plan (as de
fined by ERISA), 4=Other. If Type is 3 or 4 a Fiduciary Liability
Supplemental Application must be completed.
Please attach a separate page or use the additional information page provided at the end of the application.
Print Application
Clear Application
PIIC-NPD-NEW APP (09/06) Page 4 of 9
3. Does any plan(s) employ the investment, trustee, actuarial, legal, administrative, custodial or benefits consultin
g
services of any outside provider? Yes No If yes, please a
ttach details.
4. Has termination been request
ed or contemplated for any plan?
Yes No
5. Has any amendment to any plan been made or contemplated within the past two (2) years, or is any amendment
now contemplated, which has resulted or might result in any reduction of benefits including, but not limited to, an
increa
se in participants’ portion of cost?
Yes No If yes, please attach details. If there has been any
amendment(s), please attach copies.
6. Has any plan been spun-off (sold), transferre
d or terminated? Yes No If yes, please attach details.
7. Are there o
r have there been within the last three (3) years any know
n or alleged violations of ERISA or any
similar statutory or common law (including applicable amendments, rules and regulations) of the United States,
Canada or any state or other jurisdiction to which a plan is subject?
Yes No If yes, please attach details.
8. Doe
s the Applicant have any informat
ion to sugges
t or indicate that any of the plans it sponsors may be under
governmental or regulatory investigation with regard to the applicable plan’s funding, administration or investment
strategies?
Yes No If yes, please attach details.
9. Is Form 55
00 filed on an annual ba
sis for each plan?
Yes No If yes, provide a copy of the most recent
5500; If no, please attach details.
SECTION 5 – WORKPLACE VIOLENCE
(Complete this section only
if Workplace Violence coverage is desired.)
Please attach a copy of your employee and customer complaint/grievance procedures.
1. Workplace Violence Insurance has been continuously in force since: _________________________________
2. The Appli
cant’s total number of work locations:__
________________________________________________
3. The Appli
cant’s total number of employees: ___
__________________________________________________
4. Does the Applicant:
have an employee assistance program?
Yes No
have a prog
ressive disciplinary policy?
Yes No
have an employee comp
laint/grievance resolution procedure?
Yes No
have a written policy on workpla
ce violence that is circulated to all employees?
Yes No
train employees to re
cognize, report, and respon
d to potentially hostile situations? Yes
No
have a process for performing background checks for all potential employees?
Yes No
5. In the past twelve (12) months, ha
s the Applican
t been involved with any layoffs, staff reduction
s, or facility
closings? Yes No If yes, please attach details.
6. In the next twelve (12)
months, does the Applicant contempl
ate any layoffs, staff reductions, or facility closings?
Yes No If
yes, please attach details.
7. Has the Applicant o
r any person pro
posed for coverage herein been the subject of, or involved in, any incidents
of workplace violence in the last five years? Yes No If
yes, please attach details.
Print Application
Clear Application
PIIC-NPD-NEW APP (09/06) Page 5 of 9
SECTION 6 – INTERNET LIABILITY
(Complete this section only
if Internet Liability coverage is desired.)
1. Internet Liability Insurance has been continuo
usly in force since: ___________________
______________
2. Please identify the internet site(s) for which coverage is soug
ht, the date each site first went on-line, and (if
known)
the average number of page views per month:
Internet site address
Date on-line Average page views per month
____________________________________ ___________ ___________________________
____________________________________ ___________ ___________________________
____________________________________ ___________ ___________________________
3. Does the Applicant con
duct transactions (e-commerce) on
the site or is the site informative only?
Tra
nsactional / E-commerce (Please complete questions 4, 5 & 6)
Informational Only (Please go to question 6)
Both (Please complete questions 4, 5,& 6)
4. The Appli
cant’s pr
ojected annual gross revenue
s from the internet site: $ __________________________
5. Please describe the type and purpose of the transactions pe
rformed on the site: _________________________
_________________________________________________________________________________________
___________________
______________________________________________________________________
6. What percentage of monthly page views on the Applicant’s internet site o
riginates ou
tside the U.S. and
Canada? %
SECTION 7 – GENERAL SUMMARY
(All Applicants must
complete this section.)
1. Has the Applicant give
n written notice under the provisions of any prio
r policies providing similar insurance or
claims, or of specific facts or circumstances which might give rise to a claim being made against any person or
entity applying for this insurance? Yes No If yes, complete a Claim Supplemental for each incident.
2. No person applying for this coverage is aware of a
ny facts or circumstances which he or she has rea
son to
suppose might give rise to a future claim that would fall within the scope of any of the proposed coverages for
which the Ap
plicant has applied, except: None
or as noted below:
___________________
_____________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
3. Current Coverage
COVERAGES
Insurance Company Limit of Liability Deductible Policy Effective Dates Premium
D&O $ $ $
EPLI $ $ $
Fiduciary $ $ $
Workplace
Violence
$ $ $
Internet Liability $ $ $
General Liability $ $ $
Professional
Liability
$ $ $
Print Application
Clear Application
4. With respect to the above coverage, has any Underwriter refused, canceled or non-renewed coverage?
(Not applicable in Missouri) Yes No If yes, provide details.
Material Change
If there is any material change to the answers of this Application’s questions prior to the policy inception date, the
Applicant must notify the Underwriter in writing. Any outstanding quotation may be modified or withdrawn.
False Information
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.
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.”
NOTICE TO ALASKA RESIDENTS 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.”
NOTICE TO ARKANSAS RESIDENT 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.”
NOTICE TO ARIZONA RESIDENTS 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."
NOTICE TO COLORADO RESIDENTS 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.”
NOTICE TO 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.”
NOTICE TO 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.”
PIIC-NPD-NEW APP (09/06) Page 6 of 9
NOTICE TO 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.”
NOTICE TO LOUISIANA RESIDENTS 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.”
NOTICE TO MAINE RESIDENTS 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.”
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 PAYME
NT OF A LOSS IS GUILTY OF A
CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON."
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.”
PIIC-NPD-NEW APP (09/06) Page 7 of 9
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."
Signature
The Undersigned warrants that to the best of his/her knowledge and belief the statements set forth herein are true.
The Undersigned further declares that any occurrence or event that takes place prior to the effective date of the
insurance applied for which may render inaccurate, untrue, or incomplete any statement made will immediately be
reported in writing to the Underwriter. The Underwriter may withdraw or modify any outstanding quotations and/or
authorization or agreement to bind the insurance. The Underwriter is hereby authorized to make any investigation
and inquiry in connection with the information, statements and disclosures provided in this Application. The signing
of this Application does not bind the Undersigned to purchase the insurance, nor does the review of this Application
bind the insurance company to issue a policy. It is agreed that this Application shall be the basis of the contract
should a policy be issued. This Application will be attached and become a part of the policy.
Name (Please Print/Type) Title (
MUST BE SIGNED BY THE PRESIDENT,
CHAIRMAN OR EXECUTIVE DIRECTOR)
________________________________________________
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
Agency Taxpayer ID or SS No. Producer License No:
Address (Street, City, State, Zip)
PIIC-NPD-NEW APP (09/06) Page 8 of 9
ADDITIONAL 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
PIIC-NPD-NEW APP (09/06) Page 9 of 9
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Flexi Plus Five New App36-8642

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