Fillable GUIDES AND OUTFITTERS APPLICATION (Philadelphia Insurance Companies)

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GUIDES AND OUTFITTERS APPLICATION (Philadelphia Insurance Companies)

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GUIDES AND OUTFITTERS APPLICATION
SUBMISSION REQUIREMENTS
• All brochures describing any and all services
• 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. Does the Applicant operate any other business 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 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
State: Zip:
County: State: Zip:
Fax Number:
Risk Management’s Phone:
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 Type: Corporation Partnership Individual LLC Other:
Effective Date:
Limit of Liability requested: $ 300,000 Occurrence
$ 500,000 Occurrence
$1,000,000 Occurrence
Guides and Outfitters
Page 1 of 9
© 2018 Philadelphia Consolidated Holding Corp.
12/2018
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ACTIVITY INFORMATION
Actual Total Receipts for Prior 12 Months:
Estimated Total Receipts for Next 12 Months:
Activities Conducted
# of Guides
# of Units
User Days
Guided Fishing
Hunting
Shooting Range – Rifle or Pistol
Hiking / Backpacking
Horseback Riding
Hay, Sleigh or Wagon Rides
Lodging / Cabin Rentals
Retail Store
Bike Rentals
Mountain Bike Riding
Road Cycling
Boating
Jet Skis or Wave Runners
River Tubing
Sea Kayak Tours /Rentals
Waterskiing
Whitewater Rafting
SCUBA Diving
Cross Country Skiing
Dog Sled Tours
Downhill Skiing
Snowshoeing
ATV-guided
ATV-unguided
Snowmobiles-guided
Snowmobiles-unguided
Climbing Wall
Rock Climbing
Paintball
Youth Camps or Programs
Other, describe:
OPERATIONS INFORMATION
1.
Does the Applicant require guests to sign a liability waiver?
Yes
No
2.
Does the Applicant require guests to complete a health & physical fitness form?
Yes
No
3.
Does the Applicant have a brochure or web page?
Yes
No
4.
How many years have you been in business? Years
5.
If you are a new venture, how many years of prior experience? Years
6.
Are any operations conducted outside of the United States?
Yes
No
7.
Does the Applicant hire guides as sub-contractors?
Yes
No
If yes, for what activities?
If yes, do you obtain proof of insurance?
Yes
No
8.
Is your business operational year round?
Yes
No
If no, number of months you are operational: Months
GUIDE INFORMATION
Name
Years Experience
First Aid Qualifications
Guides and Outfitters
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12/2018
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LODGING SECTION
N/A
Guest Quarters
1.
Total number of units for guest rental?
2.
Number of RV spaces: Tent sites:
3.
Maximum guest capacity is:
4.
Do all cabins / units have smoke alarms?
Yes
No
5.
Is there a CO alarm installed?
Yes
No
6.
Does the Applicant have a swimming pool or swimming area?
Yes
No
If yes, does the Applicant have a diving board?
Yes
No
7.
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
RETAIL OPERATIONS
N/A
1.
Does the Applicant have retail operations for any of the following?
General Store
Ski Equipment Sales
Fishing Equipment Sales
Liquor Store
Ski Equipment Rental
Fishing Equipment Rental
Gun Sales
Restaurant
2.
What are the Applicant’s total annual gross sales from retail operations: $
HUNTING SECTION
N/A
1.
What is the maximum guide to guest ratio? Guides to Guests
2.
What is the maximum number of hunters at any one time?
3.
Does the Applicant operate drop camps?
Yes
No
4.
Is livestock provided with drop camps?
Yes
No
5.
What percentage of your hunting operations are unguided?
6.
What type of game is being hunted?
Elk
Deer
Exotics
Bear
Turkey
Waterfowl
Upland Birds
Hogs
Other, describe:
7.
Are tree stands used?
Yes
No
If yes, are safety harnesses required?
Yes
No
8.
Does the Applicant use any of the following to transport hunters? If yes, how many?
ATVs:
Horses:
Snowmobiles:
Boats:
Other Unlicensed Vehicles:
9.
If ATVs and/or Snowmobiles are used, are helmets required while riding?
Yes
No
BICYCLE SECTION
N/A
Tour Information
1.
Maximum number of cyclists on a tour?
2.
Maximum number of tours operating on the same day?
3.
Number of guides on a tour?
4.
Are helmets required?
Yes
No
5.
What is the percentage of tours operated: Off Road % vs. On Roadways %
6.
Does the Applicant pre-screen guests to determine ability prior to riding?
Yes
No
7.
Do guides carry any communication device with them? (2-way radio, cell phone, etc.)
Yes
No
If yes, what type?
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
Yes
No
Yes
No
%
Guides and Outfitters
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© 2018 Philadelphia Consolidated Holding Corp.
12/2018
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WATERCRAFT GENERAL INFORMATION
1.
What type of operation does the Applicant have?
Boat Rentals
Fishing Trips
Tube or Canoe Rentals
Hunting
Other:
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
Rafts
Stand Up Paddle Boards
1.
What percent of the Applicant’s operations are unguided: %
2.
Number of guides?
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 the Applicant will allow on a horse?
5.
Does the Applicant offer the use of helmets?
Yes
No
6.
Does the Applicant ever allow double riding?
Yes
No
7.
What percentage of the Applicant’s guests ride: Western Saddle: % vs. English Saddle: %
8.
What percentage of the Applicant’s horse operations are: Unguided: % vs. Guided: %
9.
What is the maximum guide to guest ratio? Guides to Guests
10. Does the Applicant operate pony rides?
Yes
No
If yes:
Trail Ride
Riding Ring
Hand Led
Other (describe):
GUEST & SAFETY INFORMATION
1.
Does the Applicant require guests to complete a physical fitness information form prior to
riding?
Yes
No
2.
Does the Applicant pre-screen guest riders and determine ability prior to riding?
Yes
No
3.
Do guides carry any communication device with them (2-way radio, cell phone, etc.?)
Yes
No
4.
Does the Applicant conduct a pre-ride safety briefing with guests?
Yes
No
5.
Does the Applicant provide a written safety manual of procedures to all staff members?
Yes
No
If yes, provide a copy.
6.
List reasons why you would decline a person from riding (health, age, weight,alcohol, general,
pregnancy):
7.
Does the Applicant board horses for a fee?
Yes
No
If yes, how many?
8.
Does the Applicant teach or allow your guest to participate in:
Dressage
Cattle Drives
Inoculations
Barrel Racing
Horse Jumping
Team Penning
Sleigh Rides
Branding Cattle
Horse Racing
Roping Cattle
Hay Rides
Handling Livestock
Buckboard / Buggy Rides
9.
Are guests allowed to handle, rope or brand livestock?
Yes
No
10.
If the Applicant conducts cattle drives, what is the number of:
Wranglers to Riders: Maximum Duration: Maximum Distance:
11.
If your ranch conducts a Rodeo/Gymkana, describe what activities your guests may
participate in:
years old
Guides and Outfitters
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12/2018
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AUTOMOBILE
1.
Does the Applicant have a formal driving policy in place with MVR standards?
Yes
No
If yes:
a.
Is driving policy communicated in writing to all employees?
Yes
No
b.
Is a signed acknowledgement form kept on file?
Yes
No
If yes, please provide a copy of signed acknowledgement.
c.
Do driving standards include the following:
i.
No major violations including DUI, racing, hit and run, speeding in excess of 20 mph
over posted speed limit, manslaughter?
Yes
No
ii.
No more than 2 moving violations within past 3 years?
Yes
No
iii.
No more than 1 at fault accident within past 3 years?
Yes
No
2.
How often does the Applicant check MVR reports?
3.
Does the Applicant allow any newly hired drivers to operate vehicles without going through a
company-specific documented driving training?
Yes
No
4.
Describe any ongoing training provided to drivers:
5.
Does the Applicant have GPS tracking capability?
Yes
No
6.
Does the Applicant allow employees to drive personal vehicles for company purposes?
Yes
No
If yes:
a.
Are the driving policy and standards for these drivers the same as in questions 1-3?
Yes
No
b.
Does the Applicant require these employees to have adequate personal insurance
limits?
Yes
No
LOSS HISTORY
Date
Description of Incident
Amount Paid/Reserved
$
$
$
1.
Does the Applicant have knowledge of any incident which may lead to a claim?
Yes
No
If yes, please describe:
Guides and Outfitters
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12/2018
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WINTER WEATHER FREEZE-UP PROTECTION
1. Fire Protection and Testing
a. Is the building provided with an Automatic Fire Sprinkler System (AS)? Yes No N/A
i. If yes, approximately what percentage (%) of the building is sprinklered? %
ii. If yes, what type of sprinkler system is installed? Wet-Pipe Dry-Pipe Both
iii. If yes, when possible, is the sprinkler piping primarily run within conditioned
areas designed to ensure the temperature remains above the 45°F minimum
Yes No N/A
iv. If yes, is the testing & inspection by qualified sprinkler contractor completed
within past 12 months & includes a formal winterization r
eview?
Yes
No
N/A
v. If yes, are the alarms tied to a 24 hour UL listed monitoring company?
Yes
No
N/A
2. Emergency Water Response (domestic and AS water lines)
a. Are water shutoff valves (domestic and AS water lines) marked and readily
accessible?
Yes
No
N/A
b. Are water shutoff valves exercised (closed and reopened) at least annually?
Yes
No
N/A
c. Is the staff qualified to respond and shut off the water main during normal business
hours and off hours?
Yes
No
N/A
3. Automatic Water Shutoff Devices
a. For domestic water lines, is there a water flow detection, notification and automatic
shutoff?
Yes
No
N/A
4. Unused/Vacant Spaces
a. Does Applicant have a formal process to turn off and drain domestic water lines for
these spaces?
Yes
No
N/A
5. Unheated Areas (attics, crawl spaces, exterior wall joists)
a. Are all domestic water lines located in areas heated to at least 45°F?
Yes
No
N/A
i. If no, please describe freeze prevention measures (e.g. temperature monitoring,
heat trace, full insulation):
This section must be completed by all risks that have a location in one of the following states: AR, CT, DC, DE,
GA, IL, IN, KY, ME, MD, MA, MI, MO, NH, NY, NJ, NC, OH, PA, RI, SC, TN, TX, VT, VA, WV, WI
temperature?
1. If no, please describe freeze prevention measures (
e.g. temperature
monit
oring, heat trace, full insulation on piping or roof):
6.
General Comments:
Guides and Outfitters
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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)
Guides and Outfitters
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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
the Applicant alleg
ing 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
SECT
ION 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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GUIDES AND OUTFITTERS APPLICATION (Philadelphia Insurance Companies)

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Completed 29 July 2020

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