Fillable GYMNASTICS FACILITIES APPLICATION (Philadelphia Insurance Companies)

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GYMNASTICS FACILITIES APPLICATION (Philadelphia Insurance Companies)

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GYMNASTICS FACILITIES APPLICATION
SUBMISSION REQUIREMENTS
• Complete ACORD applications for Property, Auto and Umbrella Liability, if coverage is requested
• Evidence of Participant Accident coverage
• Standard Accident Waiver for Participants
• Complete event schedule for special events or competitions sponsored by the Applicant
• Latest annual financial
• Currently valued insurance company loss run for the current policy period plus three (3) prior years
• Emergency evacuation plan
• Copy of safety program including rules and procedures
• Sample equipment inspection checklist
• Note that Abuse or Molestation Coverage is not available for this Product
SECTION I – GENERAL INFORMATION
1.
Applicant Name:
2.
Mailing Address:
Physical Address:
3.
Contact Person:
Telephone:
Website Address: www.
E-mail Address:
4.
Risk Management Contact:
Risk Management’s Phone:
Risk Management’s Email:
5.
Business type:
Partnership
Individual
Governmental entity
Other:
6.
Year business was established?
Number of years under present management:
FEIN:
7.
List all Named Insureds and their interests: Note: The First Named Insureds require common / majority
ownership of each Named Insured – if not, explain the relationship to insured.
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8.
Is the Applicant compliant with the Zackery Lystedt Law? (Only applicable in Washington)
Yes
No
9.
Is the Applicant a member of a sanctioning body?: (i.e. USA Gymnastics)
Yes
No
If yes, which body:
10.
Is the Applicant a franchisee?
Yes
No
If yes, name of the franchise to which the Applicant belongs:
11.
Has coverage been declined, cancelled or non-renewed in the past three (3) yrs?
Yes
No
If yes, provide details.
12.
Does the Applicant have any inflatable, fabric or air supported structures such as, but not
limited to, bubbles or domes?
Yes
No
SECTION II – GENERAL LIABILITY
Activities
Annual Number of
Participants
Annual Receipts
a.
Gymnastics:
$
Ages 1-12
Ages 13-19
b.
Aerobics
$
c.
Cheerleading
$
Ages 1-12
Ages 13-19
d.
Dance
$
e.
Martial Arts
$
f.
Swimming (monthly # of participants / # of months)
$
g.
Open gym or parents night out
$
h.
Birthday Parties (annual # of participants)
$
i.
Day Care - Complete Section IV
$
j.
Day Camps - Complete Section VI
$
k.
Overnight Camps – Section VI
$
1.
Does the Applicant sponsor any non-sanctioned gymnastics or cheerleading competitions?
Yes
No
2.
Does the Applicant use a mat or springboard floor?
Yes
No
3.
Does the Applicant provide classes, instruction or demonstration of Parkour or Freerunning?
Note these activities are excluded.
Yes
No
4.
Does the Applicant provide obstacle course classes, including but not limited to Ninja Warrior
type instruction or demonstration?
Yes
No
a.
Name of the program and description:
b.
Age range:
c.
Spotters at each obstacle?
Yes
No
d.
Who maintains the obstacles?
If a 3
rd
party, does the Applicant obtain a Certificate of Insurance naming the Applicant as
an Additional Insured?
Yes
No
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e.
List / Describe all obstacles:
Obstacle
Manufacturer
Age
5.
Does the Applicant provide Cross Fit Training or Sports Enhancement Training (other than
standard gymnastics training) for adults or children? If yes, provide detailed description.
Yes
No
6.
Does the Applicant obtain waivers and releases for all participants including adults?
Yes
No
If yes, attach copy.
Does the waiver include use of all equipment including inflatables and rock walls, if any?
Yes
No
7.
8.
Ratio of instructors to students: (day care)
Ratio of Instructors to students
Ages 0 - 18 months
to
Ages 18 months – 3 years
to
Ages 3 – 4 years
to
Over 4 years
to
9.
Trampolines or other rebounding/tumbling equipment with posted safety rules?
Yes
No
10.
Does the Applicant have a foam pit?
Yes
No
If yes, describe padding:
Supervised at all times?
Yes
No
Depth of pit:
11.
Sales of sports equipment or apparel?
Yes
No
If yes, type:
Annual receipts: $
12.
Has the Applicant completed any National Certification program?
Yes
No
If yes, what certifications does the Applicant hold:
13.
Does the Applicant own/maintain a swimming pool?
If yes, complete Swimming Pool Section XI below.
Yes No
14.
Does the Applicant own or lease the facility:
Own
Lease
If leased, who is responsible for:
Building maintenance
Applicant
Building Owner
Parking lot
Applicant
Building Owner
15.
Does the Applicant lease the facility or equipment to others?
Yes
No
If yes, does the Applicant obtain certificates of insurance?
Yes
No
16.
Is there a minimum of one staff member certified in first aid present at all times?
Yes
No
17.
Is there a minimum of one staff member certified in CPR present at all times?
Yes
No
18.
Limit of Participant Accident coverage:
Per person: $
Catastrophic: $
Ratio of instructors to students: (other than day care)
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19.
Additional Insured(s) required? Please provide list and advise relationship to insured:
SECTION III - CONCUSSIONS - ATHLETICS
1.
Does the Applicant have a written concussion awareness and management program in place,
and, where applicable, is it compliant with current state legislation?
Yes
No
If yes, does this include:
a.
Understanding a concussion and the potential consequences of this injury?
Yes
No
b.
Recognizing the signs and symptoms of a concussion or other closed head injury and
how to respond?
Yes
No
c.
Learning about steps for returning to activity after a concussion?
Yes
No
d.
Focusing on prevention and preparedness to help keep participants safe?
Yes
No
*A copy of written program is required upon binding.
2.
Does the insured require all coaches, instructors, and officials to complete the online
Concussion Course offered by the Centers for Disease Control and Prevention?
Yes
No
3.
a.
Does the insured communicate and distribute education materials to participants and / or
parents / guardians of minors about the nature of risk of concussions, including but not
limited to how to recognize concussion symptoms, in written or electronic form?
Yes
No
b.
Does the insured require the participants and / or parents / guardians of minors to sign an
acknowledgment that they have received and reviewed?
Yes
No
4.
If a concussion is suspected, does the Applicant require the participant to leave the game or
practice immediately?
Yes
No
5.
Does the Applicant mandate that participants suspected of suffering a concussion can only
return after at least 24 hours and with written clearance from a licensed physician before being
allowed to return to play?
Yes
No
6.
Does the Applicant utilize base line testing?
Yes
No
7.
Does the Applicant currently utilize any concussion impact monitoring technology?
Yes
No
If yes:
a.
Describe:
b.
Advise the name of the manufacturer:
c.
Advise who monitors the data:
Coaches
Employees
Volunteers
3
rd
Party
SECTION IV – DAY CARE CENTERS
1.
Is the day care licensed?
Yes
No
NOTE: Unlicensed day care centers are not eligible under this program.
2.
Has the Applicant’s license ever been denied, suspended or revoked?
If yes, provide details:
Yes
No
3.
Is the day care separated from the gymnastics facility?
Yes
No
If no, how are children kept away from equipment:
4.
Exits directly to the outside on the ground floor?
Yes
No
5.
Are bathroom doors locked?
Yes
No
Can they be unlocked from the outside?
Yes
No
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6.
Are premises child proofed to eliminate potential hazards?
Yes
No
7.
Has lead abatement been performed since 1971?
Yes
No
8.
Any exposure to asbestos materials?
Yes
No
9.
Any staff under the age of 18 years old?
Yes
No
10.
Does the Applicant have volunteers? If yes, indicate duties:
Yes
No
11.
Does the Applicant provide sick child, drop in, latch-key, boarding or camp services?
Yes
No
If yes, describe:
12.
Does the Applicant care for special needs children? If yes, describe.
Yes
No
13.
Does the Applicant maintain the following:
Immunization records – updated annually?
Yes
No
Records for each child indicating unusual conditions the child has?
Yes
No
Signed releases for emergency medical treatment obtained from parents?
Yes
No
Written instructions from child’s physician for dispensing medication?
Yes
No
14.
Is there an outside play area? If yes, describe security, i.e. fencing, gates, locks, etc.
Yes
No
SECTION V - INFLATABLES
NOTE: Off-premises use or rental of inflatables is excluded.
1.
Please provide a list of inflatables commonly owned/used.
2.
Does the Applicant use any inflatables outside of its building?
Yes
No
3.
Are inflatables checked daily and maintenance logs maintained?
Yes
No
SECTION VI – ROCK CLIMBING AND BOULDERING WALLS
NOTE: Off-premises use or rental of rock walls is excluded.
1.
Does rock wall meet all CWIG (Climbing Wall Industry Group) standards and local codes?
Yes
No
2.
What is the height of the wall:
Bouldering (traversing) wall only – 6’ or less?
Yes
No
3.
Are participants allowed to climb on their own?
Yes
No
4.
What is the check-in procedure:
5.
What kinds of verbal contacts or warnings given:
6.
When is safety testing done:
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7.
What type certification system is used:
8.
What type of equipment is used:
Describe the belay system:
9.
What type of landing surface is used: (Describe makeup, thickness and extent of fall protection)
10.
Who is responsible for daily maintenance and checks:
11.
Are spotters required?
Yes
No At what height:
12.
Does the Applicant have a portable wall?
Yes
No
If yes, what is frequency of use off premises:
13.
Is there a separate charge for use of the wall?
Yes
No
If yes, please provide annual receipts. $
SECTION VII – MARTIAL ARTS
1.
Are instructors certified in Martial Arts?
Yes
No
If yes, list qualifications, including belt rank:
2.
List styles taught and age groups:
3.
Does the Applicant sponsor on site tournaments with other schools?
Yes
No
4.
Are kicking motions to the head permitted during sparring?
Yes
No
5.
Does the Applicant offer self-defense programs?
Yes
No
6.
Does the Applicant offer weight/strength training?
Yes
No
7.
Is free sparring permitted?
Yes
No
If yes, light contact or full contact:
If yes, are rules posted and signed by owner?
Yes
No
Are kicking motions to the head permitted in sparring?
Yes
No
8.
Describe protective gear required:
SECTION VIII – BIRTHDAY PARTIES
1.
Are birthday party attendees allowed on gymnastics equipment, trampolines or rock walls?
If yes, please describe protection and supervision:
Yes
No
2.
What is the average number of attendees per party:
Age group:
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3.
What is the ratio of staff to attendee:
4.
Does the Applicant serve food?
Yes
No
If yes, what type:
5.
Are parents permitted to bring food on premises for parties?
Yes
No
6.
Briefly describe activities and equipment attendees are permitted to use for parties:
SECTION IX – CAMPS / CLINICS
1.
Day Camp
# of Campers:
# of Camper Days:
Overnight Camp
# of Campers:
# of Camper Days:
2.
All counselors / leaders 18 years or older?
Yes
No
3.
Supervisor on duty at least 25 years or older at all times?
Yes
No
4.
Overnight camps?
Yes
No
Describe sleeping arrangements:
Any water hazard exposure?
Yes
No
Describe:
Are camps co-ed?
Yes
No
SECTION X - CHEERLEADING
1.
Does the Applicant participate in competitive cheerleading?
Yes
No
If yes, what levels (i.e. junior high, senior high?):
Are individual cheerleader abilities and skill levels assessed on an annual basis for team
placement?
Yes
No
2.
Does the Applicant follow NACCC or USASF recommended guidelines for spotters?
Yes
No
3.
Does the Applicant train students on proper spotting techniques?
Yes
No
4.
Are teams / individuals supervised at all times by qualified coaches?
Yes
No
5.
Type of floor protection:
Mats
Springboard
6.
Are pyramids permitted higher than 2 ½ people?
Yes
No
Are only advanced students allowed to perform pyramids higher than 2 people?
Yes
No
Does the Applicant allow tossing from one base to another base?
Yes
No
7.
Does the Applicant participate in competitions governed by NACCC/USASF rules?
Yes
No
If no, provide rules that are followed.
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SECTION XI – SWIMMING POOLS
1.
Are all swimming pools and spas compliant with Virginia Graeme Baker Pool and Spa
Safety Act? If no, provide timetable and action plan:
Yes
No
2.
Is use of the pool limited to registered students only? If no, describe:
Yes
No
3.
Are birthday party attendees (if any) permitted to use the pool?
Yes
No
4.
Is a lifeguard on duty at all times pool is in use?
Yes
No
5.
What is the depth of the pool:
Feet
Distance between depth markers:
Feet
6.
Does the Applicant have any of the following features:
Diving Board? If yes, height of board:
Yes
No
Water Slide? If yes, height of slide:
Yes
No
7.
Above Ground?
Yes
No
In Ground?
Yes
No
8.
Indoor?
Yes
No
Outdoor?
Yes
No
9.
Is there a slip-proof surface surrounding pool area?
Yes
No
SECTION XII - HIRED AND NON-OWNED AUTO
1.
Does the Applicant have any owned automobiles?
Yes
No
NOTE: If insured has owned autos, the hired car and non-owned auto coverage should be
placed with the automobile carrier. Explain if an exception is requested.
2.
Does the Applicant allow employees to use their own personal vehicles for its business
purpose?
Yes
No
If yes, how many employees use their own personal vehicles:
If yes, how often?
Daily
Weekly
Monthly
Other:
3.
Does the Applicant obtain Motor Vehicle Reports?
Yes
No
If yes, how often:
Annually
Every other year
Other:
4.
Does the Applicant confirm that all employees who regularly use their cars for business
purposes carry minimum personal auto limits?
Yes
No
If yes, what minimum limits are required: $
5.
Please provide the approximate cost of hire for all hired or leased autos during the course of
the policy period: $
6.
Is hired auto physical damage required?
Yes
No
If yes, what is the maximum value of hired vehicle the Applicant would like insured? $
NOTE: Hired Car Physical Damage deductibles: $100 comprehensive / $1,000 collision provided.
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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)
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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 again
st the 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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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
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, 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 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.
NAM
E (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
____________________________________________________
SIGNATURE DATE
SECT
ION TO BE COMPLETED BY THE P
RODUCER/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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GYMNASTICS FACILITIES APPLICATION (Philadelphia Insurance Companies)

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Completed 29 July 2020

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