Fillable Flexi Plus Five Renewal App36-11169

Fill Online, Printable, Fillable, Blank Flexi Plus Five Renewal App36-11169 Form

Use Fill to complete blank online PHILADELPHIA INSURANCE COMPANIES pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Flexi Plus Five Renewal App36-11169

On average this form takes 37 minutes to complete

The Flexi Plus Five Renewal App36-11169 form is 7 pages long and contains:

  • 0 signatures
  • 11 check-boxes
  • 143 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Philadelphia Insurance Companies forms online.

BROWSE PHILADELPHIA INSURANCE COMPANIES FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
FLEXI PLUS FIVE RENEWAL APPLICATION
NOT-FOR-PROFIT ORGANIZATION DIRECTORS AND OFFICERS LIABILITY INSURANC
E
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 an
d its wholly-
owned/controlled subsidiaries.
• The Applicant is required to complete Sections 1, 2, and 7.
• The Applicant should
complete other applicable Se
ction(s) for which coverage is desired. (See chart
below)
• Please include all requested underwriting information and attachments. Failure to supply may result in
delay.
Che
ck 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. Change in Address:
None or Change in internet address: None or
www.
Billing contact name:
3. Has there been any changes in the Applicant’s op
erations?
Yes No If yes, please provide details.
4. Does the Applicant hav
e a tax-exem
pt status un
d
e
r the U.S. Internal Reven
ue Co
de?
Yes No
If no, provide an explanation.
5. The Officer of the Applicant designated to receive any and all notices from th
e Underwriter or their authorized
representative concerning this insurance is:
Name Title E-mail Address
PIIC-NPD-RENEWAL APP (05/10) Page 1 of 7
Clear Application
Print Application
PIIC-NPD-RENEWAL APP (05/10) Page 2 of 7
FINA
NCIAL 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
tax form.
SECTION 2 – DIRECTOR
S AND OFFICERS
(All Applicants must
complete this Section)
1. In the past twelve (12) months or the next twelve (12) month
s, has the Applica
nt been or anticipate being
involved in ay of the following? If yes attach details.
Creation of any new subsidiaries?
Yes No
Mergers, acquisitions or consolidation with another entity?
Yes No
Changes in the board of directors or senior management (other than death or retirement)?
Yes No
SECTION 3 – EMPLOYMENT PRACTICES
(Comple
te this section only
if Employment Practices Liability coverage is desired.)
1. 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 ____________ ____________ _____________
2. How many employees have been terminated or de
moted in the past twelve (12) months?
Voluntary:
Involuntary: Laid Off: Demoted:
3. Is any reduction of employees or change of statu
s anticipated in
the next year?
Voluntary: Involuntary:
Lay Offs:
Demotions:
4. Has the Applicant implemented any new employment pra
ctice/human resource polici
es or procedures?
Yes No If yes, please provide details.
Clear Application
Print Application
PIIC-NPD-RENEWAL APP (05/10) Page 3 of 7
SECTION 4 – FIDUCIARY LIABILITY
(Complete this section only
if Fiduciary liability coverage is desired.)
1. 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 $1,000,000 2 75 self
a)
b)
c)
d)
Please attach a separate page or use the additional information page provided at the end of the application.
* 1=Employee Welfare Benefit Plan (as defined by ERISA), 2= De
fined Contribution Plan (a
s defined by ERISA),
3= Defined Benefit Plan (as defined by ERISA), 4=Other. If Type is 3 or 4 a Fiduciary Liabilit
y Supplemental
Application must be completed.
2. Have there been any changes to any plan listed above?
Yes No If yes, please attach details.
3. Has any plan requested or contemplated filing a request for termination?
Yes No If yes, please attach
details.
4. Has any plan been spun-off (sold), transferred or terminated?
Yes No If yes, please attach details.
Please attach a Form 5500 for each plan listed above.
SECTION 5 – WORKPLACE VIOLENCE
(Complete this section only
if Workplace Violence coverage is desired.)
1. Has the Applicant ad
ded additional work lo
cations?
Yes No If yes, please attach details.
2. The Appli
cant’s total numbe
r of employees:
3. Has the Applicant implemented any new employment proced
ures, office proc
edures, or security procedures?
Yes No If yes, please attach details.
4. In the past twelve (12) months or in the next twelve (12) months, has the Applicant b
een involved with or
anticipate any layoffs, staff reductions, or facility closi
ngs?
Yes No If yes, please attach details.
SECTION 6 – INTERNET LIABILITY
(Complete this section only
if Internet Liability coverage is desired.)
1. Has the Applicant cre
ated any new web
sites? Yes No If yes please provide the site address(es)?
2. Has the Applicant ma
de any material
changes to the existing site?
Yes No If yes, please provide
details.
Clear Application
Print Application
PIIC-NPD-RENEWAL APP (05/10) Page 4 of 7
SECTION 7 – GENERAL SUMMARY
(All Applicants must
complete this Section.)
1. Has the Applicant be
en the subject or involved in any litigation in the past twelve (12) month?
Yes No
If yes, please complete a supplemental claim form.
2. In the next
twelve (12) months, does the Applicant anticip
ate any substantial change o
r reorganization of
operations
? Yes No If yes, please provide details.
If there is any material change to the answers of the Application’s questions prio
r 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.”
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.”
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.”
Clear Application
Print Application
PIIC‐NPD‐RENEWALAPP(05/10)Page5of7
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.”
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 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: I
F
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 PAYMENT OF A LOSS IS GUILTY OF A
CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON."
Clear Application
Print Application
PIIC‐NPD‐RENEWALAPP(05/10)Page6of7
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.”
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."
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
Producer License Number Agency Taxpayer ID or SS Number
Address (Street, City, State, Zip)
Clear Application
Print Application
PIIC-NPD-RENEWAL APP (05/10) Page 7 of 7
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
Clear Application
Print Application
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Flexi Plus Five Renewal App36-11169

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 2 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document