Fill - Free fillable GOLF COURSE SUPPLEMENTAL APPLICATION* (Philadelphia Insurance Companies) PDF form

1. Type of Course: Championship/Tournament Executive

2. Number of Holes: 9 18 36 Other

GROUNDSKEEPING

1. Are all employees who apply pesticides and other herbicides licensed by the state? Yes No

2. Is the course sprayed when not in use? Yes No

3. Are signs posted when spraying has been done? Yes No

4. Chemicals are stored locked and secured area above water table

5. Is there a leak/spill containment plan? Yes No

6. Are any “restricted use” chemicals used?

Are they properly marked?

Yes No

7. Are Material Safety Damage Sheets (MSDS) used? Yes No

8. Are labels on all chemical containers? Yes No

9. Is there an eye wash facility or shower available for emergencies? Yes No

10. Are there underground chemical storage tanks?

If yes, do tanks meet current EPA tank standards?

Yes No

11. How close are the storage and mixing areas to groundwater supplies, lakes, ponds or rivers that could

receive runoff from a spill or leak?

100’-less 100’-500’ 500’-1000’ 1000’-1/2mi. 1/2mi.-1mi. Over 1mi.

12. Have any clean-up orders been received? Yes No

If yes, please describe:

GOLF CART STORAGE

1. Type of building:

2. Are golf carts stored in locked buildings? Yes No

3. Do you have grounding of electrical cart charging equipment? Yes No

4. Is there adequate ventilation in the recharging area? Yes No

5. Do golf carts meet safety requirements established by American National Safety

Institute regarding design and operation of carts? (ANSI 1Z130, 1-1979) Yes No

6. Do you have grounding of electrical cart charging equipment? Yes No

7. Quality and maintenance of carts is: Excellent Good Adequate Needs Improvement

GOLF COURSE SUPPLEMENTAL APPLICATION*

*to accompany General Application

Risk Management’s Phone:

amed Insured:

Risk Management Contact:

Risk Management Email:

Golf Course Supplemental

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11/2018

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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 T

O 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)

Golf Course Supplemental

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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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