Fillable HEALTH AND FITNESS CLUB SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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HEALTH AND FITNESS CLUB SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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HEALTH AND FITNESS CLUB SUPPLEMENTAL APPLICATION
Applicant Name:
Mailing address:
Billing address:
Web address:
Type of operation:
Individual
Partnership
Corporation
Contact name: Phone number:
FEIN number: SIC code: Years in business:
Are you an IHRSA member? Yes No
Have you taken a PASS assessment? Yes No
If yes, PASS ID: PASS Score (1-4 Bells):
If no, please contact your Agent to conduct an initial assessment at http://www.losscontrol.com/PASS/PASS3.aspx
.
SUBMISSION REQUIREMENTS
• Completed and signed / dated PHLY Health and Fitness Supplemental application
• Completed ACORD application(s)
• Currently valued insurance company loss runs for the current policy period plus three (3) prior years
• Copy of health club membership application, including waiver language
• Copy of medical disclosure
• Brochure, advertising materials, and website information
SECTION I - PREVIOUS CARRIER INFORMATION
Carrier Expiration Annual Premium
Property $
General Liability $
Crime $
List any property or liability claims in the previous three (3) years:
SECTION II – GENERAL LIABILITY COVERAGE
General Aggregate $3,000,000 $2,000,000 $1,000,000 $300,000
Products/Comp Ops Agg $3,000,000 $2,000,000 $1,000,000 $300,000
Personal Injury $1,000,000 $1,000,000 $500,000 $100,000
Occurrence $1,000,000 $1,000,000 $500,000 $100,000
Fire Legal $50,000 $50,000 $50,000 $50,000
Medical Expense $1,000 $1,000 $1,000 $1,000
Increase Fire Legal limit to: $ (only if other than $50,000)
BI/PD deductible: $250 $500 $1,000 Per Occurrence
Hired and Non-Owned coverage limit? Yes No
Umbrella policy limit requested? Yes No If yes, what limit? $
Employers Liability limit: $ Employers Liability carrier:
Health and Fitness Club
Supplemental Application
Page 1 of 10
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06/2017
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Additional Insured(s)
Lessor of leased equipment:
Lessor of premises:
Mortga
gee:
Grantor of franchise:
SECTION III – PROPERTY SECTION
Building(s)
Loc.
No.
Bldg.
No.
ACV/RC Limit of
Insurance Coinsurance Address
$
$
$
$
Contents (Includes Improvements & Betterments)
Loc.
No.
Bldg.
No.
ACV/RC Limit of
Insurance
Coinsurance Address
$
$
$
$
Deductible: $500 $1,000 Other: $
Business Income: Limit of Insurance: $ (Monthly Limit of Indemnity Form)
Monthly Limitation: 1/3 1/4 1/6
Construction of building:
Walls: Wood frame Brick / Brick Steel frame Other:
Roof: Wood frame Poured concrete Steel frame Other:
Floor: Wood frame Concrete Other:
Signs
Type
Value Location
1. $
2. $
3. $
Year built: Square footage: Age of roof:
Yes No
Does the Applicant have any air supported or fabric roof structures on premise? (Tennis bubbles,
Event tents, etc…)
Does the property have automatic fire sprinklers? Yes No
Hydrant: Fire station: Distance to:
Burglar Alarms: Local Central station only w/keys Central station w/o keys
Yes No
Yes No
Yes No
Yes No
Does the property have aluminum wiring?
If yes, has it been retrofitted with one of the PIC approved connectors and by a licensed electrician?
(Indicate which one): COPALUM? Yes No AlumiConn?
Date updated?
Please supply retro-fit documentation or statement from installing contractor.
Does the Applicant own the building?
If no, who does?
Mortgagee: Loss Payee:
Health and Fitness Club
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Flood
Does the Applicant have a current flood policy in force? Yes No
If yes, attach a copy of the declarations sheet.
If no, would you like a flood quote with our proposal? Yes No
(Flood quote will be secured through the Write Your Own Flood Program)
Crime Coverage
Theft, Disappearance & Destruction
Loss Inside the Premises: $ Loss Outside the Premises: $
Employee Dishonesty: $
Number of officers and employees who have custody of the money:
By whom is financial audit completed? Frequency of audits?
Is there a countersignature procedure in place? Yes No
Frequency of bank deposits:
Are accounts reconciled by someone not authorized to deposit or withdraw monies? Yes No
SECTION IV – RISK SURVEY QUESTIONNAIRE
1. Gross sales: $
Memberships: % Retail: % Alcohol % Tanning %
2. Payroll: $
3. Number of members at this location (both active and non-active):
4. Number of active members:
(Number of members, not number of active members is used as GL rating base)
5. Number of employees: Management: Physical Therapy: Personal Trainers:
Administrative: Other:
6. Number of sub-contractors:
Services sub-contracted:
7. Are certificates of insurance obtained from Applicant’s sub-contractors? Yes No
If yes, provide a copy.
8. Is the Applicant looking to provide coverage for any of the above under the policy? Yes No
If yes, who?
9. How many personal trainers are employed / sub-contracted at Applicant’s facility?
10. What percent of the personal trainers are certified by ACE, NSCA, NCSF, or other agency
accredited through NCCA? %
11. Any property leased to others? Yes No
If yes, explain:
Please provide square footage leased:
12. Any events held off premises by the Applicant? Yes No
If yes, explain:
13. Number of guests per mo
nth:
14. Are guests required to sign waiver of liability forms? Yes No
15. Are waivers obtained for all adult users of the club, including spouses / partners on family
memberships? Yes No
16. Are medical disclosure forms requested of all members? Yes No
17. Is an incident log kept of all injuries and accidents? Yes No
18. Are all guests and members instructed on how to use equipment on a continuing basis? Yes No
19. Is a pre-
workout evaluation done by a fitness trainer for new members? Yes No
20. Are written instructions of use on each piece of equipment? Yes No
Health and Fitness Club
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21. Are “spotters” required for all free weights? N/A Yes No
22. Are showers and locker rooms disinfected and cleaned daily? Yes No
How often?
23. Are there non-slip surfaces in shower areas? Yes No
24. How many Automatic External Defibrillators (AED) does the Applicant have at each location?
25. How many employees at each location are trained to operate an AED?
26. Was full CPR training included with the AED training? Yes No
27. What are the Applicant’s hours of operation?
28. Is staff present during all hours of operation? Yes No
29. Is there a snack bar or restaurant on the premises? Yes No
If yes, square footage occupied?
30. Is there a bar serving liquor? Yes No
If yes, square footage occupied?
31. Is there any volunteer labor or “free membership / work exchange”? Yes No
32. Is there a pro shop? Yes No
If yes, square footage occupied?
33. Are any products sold with the Applicant’s name or label on them? Yes No
34. Are dietary supplements sold? Yes No
If yes, what brand names:
Free weights: lbs. Masseuse / Masseur Yes No
Lifecycles : # Is this sub-contracted? Yes No
Rowing machines: # Aerobics Yes No
Step machines: # Is this sub-contracted? (please attach a schedule) Yes No
Roller blading or skating: # Martial Arts Yes No
Treadmills: # Is this sub-contracted? Yes No
Rock climbing apparatus: # Barber Yes No
Racquetball courts: # Is this sub-contracted? Yes No
Locker rooms: # Dance instruction Yes No
Jogging track: # Is this sub-contracted? Yes No
Showers: # Walking program off premises? Yes No
Steam room: # Physical therapists Yes No
Sauna: # Is this sub-contracted? Yes No
Tennis Bubbles: #
sq. ft = Number of therapists:
Tennis courts: Indoor: # sq. ft. = Outdoor # sq. ft. =
Whirlpools / Jacuzzi: # Indoor or Outdoor How often is water tested?
What temperature is the water kept? How many are in the club?
Basketball courts: Indoor # Outdoor #
Circuit equipment: # of pieces: Square footage:
1. Is Applicant seeking a quote for Abuse & Molestation coverage? Yes No
If no, skip this section.
2.
Yes No
3.
Does Applicant’s state permit criminal background investigations? Yes No
If yes, does the Applicant routinely request and receive such background investigations? Yes No
4. Will any independent contractors have access to clients or children in a closed door setting
or perform operations where they will be physically touching another person? Yes No
a. Does the Applicant perform background checks on hired independent contractors? Yes No
b. If no, please explain:
5. Does the Applicant verify employment-related references? Yes No
6. Does the Applicant conduct a personal interview? Yes No
7. Yes No
Does the Applicant have written procedures for dealing with sexual abuse? If yes attach a copy.
SECTION V - FACILITIES AND SERVICES
(Supply an inventory list with values where applicable.)
SECTION VI - ABUSE AND MOLESTATION
Does the Applicant’s employment process (for employees and volunteers) include
verification of whether the individual has ever been convicted of any crime, including sex-
related or child-abuse related offenses, before an offer of employment is made?
Health and Fitness Club
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8.
Does the Applicant have a plan of supervision that monitors staff in day-to-day relationships
with clients, both on and off premises? Yes No
9. a. Has the Applicant ever had an incident which resulted in an allegation of sexual
abuse? If yes, describe: Yes No
b. Was a claim made against the Applicant? Yes No
c. Was the case settled? Yes No
d. Was the case taken to trial? Yes No
e. How much money was paid as damages to the victim? $
10.
Regarding coverage for Abuse & Molestation, does the Applicant’s current policy:
Exclude coverage
Limit coverage (please indicate limit): $
Neither exclude or limit coverage
11. Please indicate age range of clients: From: To:
1. Is the pool a lap pool? Yes No
If yes, how deep? Indoor Outdoor
2. Depth markings are located at what intervals?
3. How often is water tested?
4. Is there a diving board? Yes No
5. Is there a slide? Yes No
6. Is a lifeguard present? Yes No Are they certified? Yes No
7. Are SWIM AT YOUR OWN RISK signs posted with pool rules? Yes No
8. Are all swimming pools and spas compliant with Virginia Graeme Baker Pool and Spa
Safety Act? If no, provide a time table and action plan: Yes No
9. Hours of operations:
10. Is the pool rented out for parties? Yes No
If yes, explain:
1. What are the ages of children under care?
2. Maximum length of stay?
3. Are waivers signed by parents? Yes No
4. Maximum number of children at one time?
5. Ratio of staff to children:
6. Qualifications of staff:
7. Activities occurring:
SECTION VII - SWIMMING POOLS
SECTION VIII - DAY NURSERY / BABYSITTING
Health and Fitness Club
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8. Is there a playground? Yes No
If yes, type of equipment?
If outdoor, what type of surface is under the equipment?
What type of supervision is given to the playground?
1. Number of units?
Type:
Manufacturer:
2. Are goggles required? Yes No
3. Are token timers used? Yes No
4. Are
operators present? Yes No
5. Are controls on the outside of the booth/bed? Yes No
6. Tanning booth waiver signed by members? Yes No
7. Are only the manufacturer suggested bulbs used? Yes No
8. Type of bulbs used: UVA %: UVB %:
9. Are warning signs posted regarding ultraviolet rays? Yes No

1. Please check the professional services that you perform and for which you de
sire coverage under
the policy, and
provide the annual receipts for each.
NOTE: Any professional service for which the Applicant does not provide such information will not be covered
under the policy.
NOTE: Checking a professional service does not obligate us to insure it.
Professional Service
Annual Receipts
Electrolysis $
Microdermabrasion** $
Waxing $
Manicure or Pedicure $
Body wraps for weight / water reduction $
Hair cutting / Styling / Coloring $
Facial / Scalp massage $
Personal trainers / Yoga instructors $
Ear piercing $
Body piercing (other than ear lobe) $
Facial and skin cleansing $
Hydrotherapy $
Aromatherapy $
Endermology $
Body wraps for other than weight / water reduction $
Body massage $
Cosmetics / Make-up application $
Tanning beds / booths / units $
Tattoo or Micropigmentation $
Teeth whitening $
Chemical Peels –
What percentage concentration of active
ingredients? %
$
Exercise / Workout $
Beautician service / Hair $
Sale of products $
SECTION IX - TANNING APPARATUS
SECTION X - SPA OPERATIONS
(If the Applicant performs spa operations, please complete the following.)
Health and Fitness Club
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Tanning $
Other services not listed above (describe):
$
$
$
2. Does the Applicant provide any of the following services?
Acupuncture Permanent make-up
Chiropractic Tattooing
Laser Hair Removal Botox or injections of any kind
IF ANY SERVICES ABOVE ARE PROVIDED, YOU ARE NOT ELIGIBLE FOR THIS PROGRAM.
3. Provide the number for each: Employees (part-time is less than 10 hrs/week) and independent contractors. Do
not include the owner.
Employees Independent Contractors
Staff Full-time Part-time Full-time Part-time
Aestheticians
Masseuse
Body wrap technicians
Manicurists
Beauticians
Electrologist
Pilates instructors
Yoga instructors
Fitness instructors
Aerobic instructors
Students (Aesthetician or Electrologist)
Office Staff
4. Are all technicians licensed if required by law? Yes No
5. Please provide the number of the following: Pools: Jacuzzis: Steam/Saunas:
Tanning Beds / Booths : Hydrotherapy Tables / Tubs: Exercise Equipment:
6. Does the Applicant’s equipment comply with, and are you aware of, all requirements of federal
and state regulatory agencies?
Yes
No
7. Do independent contractors or booth renters conduct operations on applicant’s premises? Yes No
8. Are the work areas where acrylics are used well ventilated? Yes No
9. Do all employees receive safety instruction to avoid potential eye contamination by
chemicals?
Yes
No
10. Are all body contact supplies sanitized after each use? Yes No
11. Are toxic chemicals stored away from the access of customers? Yes No
12. If the Applicant’s clients operate any exercise equipment, are they instructed and monitored? Yes No
13. Is the Applicant’s business located in a private residence? Yes No
If yes, is there a separate entrance? Yes No
14. Does the Applicant manufacture or re-package any product? Yes No
15. Is any product manufactured and distributed under your private label? Yes No
If yes, describe the product and attach proof of manufacturer coverage:
16. Does the Applicant use, and save as a permanent record, a hazard disclosure and personal
injury disclaimer or waiver for each customer for all services performed?
Yes
No
17. Does the Applicant have a medical crisis plan? Yes No
18. Does the Applicant require health histories, intake questionnaires? Yes No
If yes, how long are they kept?
19. Does the Applicant require signed waivers from all clients? Yes No
20. Is signage used throughout the facility to prevent injury? Yes No
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21. Does the Applicant have non-slip surfaces in all wet areas? Yes No
22. Does the Applicant sub-lease any space to others? Yes No
23. Does the Applicant’s facility have a restaurant / snack bar? Yes No
24. Name and address of equipment lessor who requires inclusion as additional interest:
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SECTION XI - 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 review?
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
monitoring, heat trace, full i
nsulation on piping or roof):
6.
General Comments:
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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
SEC
TION 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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HEALTH AND FITNESS CLUB SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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Completed 29 July 2020

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