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HIGH INTENSITY FUNCTIONAL FITNESS APPLICATION AND RISK SURVEY (Philadelphia Insurance Companies)

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HIGH INTENSITY FUNCTIONAL FITNESS
APPLICATION AND RISK SURVEY
SUBMISSION REQUIREMENTS
•
Completed and signed / dated PHLY High Intensity Functional Fitness application and risk survey
• 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 maintenance agreements with equipment providers
GENERAL INFORMATION
Applicant:
Mailing address:
Billing address:
Web address:
Type of operation:
Individual
Partnership
Contact name:
Phone number:
FEIN number:
SIC code:
Years in business:
Crossfit Affiliate?
Yes
No
Is there an Accident / Medical Policy in place?
Yes
No
If yes, what limits are carried (Per Accident)?
None
$5,000
$10,000
$25,000
$50,000
$100,000
$1,000,000
Are there procedures in place to verify that individuals and parents carry their own health insurance?
Yes
No
If the Applicant does not have Accident / Medical coverage, do they need a quote?
Yes
No
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 limits: $
Employers Liability carrier:
Additional Insured(s)
Lessor of leased equipment:
Lessor of premises:
Mortgagee:
High Intensity Functional Fitness
Application and Risk Survey
Page 1 of 6
© 2017 Philadelphia Consolidated Holding Corp.
06/2017
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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:
Year built:
Square footage:
Age of roof:
Does the Applicant have any inflatable, fabric or air supported structures such as, but not limited to
bubbles or domes?
Yes
No
Does the property have automatic fire sprinklers?
Yes
No
Distance to: Hydrant:
Fire station:
Burglar Alarms:
Local
Central station only w/keys
Central station w/o keys
Does the property have aluminum wiring?
Yes
No
If yes, has it been retrofitted with one of the PHLY approved connectors and by a licensed electrician?
Yes
No
(Indicate which one):
COPALUM?
Yes
No
AlumiConn?
Yes
No
Date updated?
Please supply retro-fit documentation or statement from installing contractor
Does the Applicant own the building?
Yes
No
If no, who does:
Mortgagee:
Loss Payee:
Signs
Type
Value
Location
1.
$
2.
$
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 the Applicant like a flood quote with our proposal?
Yes
No
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:
High Intensity Functional Fitness
Application and Risk Survey
Page 2 of 6
© 2017 Philadelphia Consolidated Holding Corp.
06/2017
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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: %
2.
Payroll: $
Annual Member Fee: $
Monthly Member fee: $
3.
Up to age 12
Ages 13 -16
Age 17 and older
Total Participants
4.
Number of employees:
Management:
Physical Therapy:
Personal Trainers:
Administrative:
Other:
5.
Number of sub-contractors:
Services sub-contracted:
6.
Are certificates of insurance obtained from the Applicant’s sub-contractors?
Yes
No
If yes, provide a copy.
7.
Is the Applicant looking to provide coverage for any of the above under the policy?
Yes
No
If yes, who:
8.
How many personal trainers are employed / sub-contracted at the Applicant’s facility:
9.
How many of the personal trainers are Crossfit certified:
10.
Any property leased to others? If yes, explain:
Yes
No
Please provide square footage leased:
11.
Any events held off premises by the Applicant? If yes, explain:
Yes
No
12.
Number of guests per month:
13.
Are guests required to sign waiver of liability forms?
Yes
No
14.
Do all members sign a waiver of liability form prior to receiving membership?
Yes
No
15.
Are medical disclosure forms requested of all members?
Yes
No
16.
Is an incident log kept of all injuries and accidents?
Yes
No
17.
Are all guests and members instructed on how to use equipment on a continuing basis?
Yes
No
18.
Is a pre-workout evaluation done by a fitness trainer for new members?
Yes
No
19.
Are exercise instructions and demonstrations given on each exercise and WOD?
Yes
No
20.
Are all workouts monitored?
Are members permitted to train without supervision?
N/A
Yes
Yes
No
No
21.
Are showers and locker rooms present?
Yes
No
22.
If yes, are there non-slip surfaces in shower areas?
Yes
No
23.
How many Automatic External Defibrillators (AED) does the Applicant have at each location?
24.
How many employees at each location are trained to operate an AED?
25.
Was full CPR training included with the AED training?
Yes
No
26.
What are the Applicant’s hours of operation:
27.
Is staff present during all hours of operation?
Yes
No
28.
Is there a snack bar or restaurant on the premises?
Yes
No
If yes, square footage occupied:
29.
Is there a bar serving liquor?
Yes
No
If yes, square footage occupied:
30.
Is there any volunteer labor or “free membership / work exchange”?
Yes
No
31.
Is there a pro shop?
Yes
No
If yes, square footage occupied:
32.
Are any products sold with the Applicant’s name or label on them?
Yes
No
33.
Are dietary supplements sold?
Yes
No
If yes, what brand names:
34.
Are Crossfit Kids programs run at this facility?
Yes
No
35.
Who is responsible for equipment installation (ropes, pull up bars, etc)?
High Intensity Functional Fitness
Application and Risk Survey
Page 3 of 6
© 2017 Philadelphia Consolidated Holding Corp.
06/2017
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SECTION V - 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 VI - FACILITIES AND SERVICES
(Supply an inventory list with values where applicable)
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
Tires: #
Martial Arts
Yes
No
Treadmills: #
Is this sub-contracted?
Yes
No
Rock climbing apparatus: #
Running program off premises?
Yes
No
Sledgehammers: #
Physical therapists
Yes
No
Rings: #
Is this sub-contracted?
Yes
No
Climbing ropes: #
Number of therapists:
Box Platforms: #
Steam room/Sauna: #
Sleds: #
Tennis Bubbles: # sq. ft =
Circuit equipment (balls, bars, kettlebelles): # of pieces:
sq. ft.=
High Intensity Functional Fitness
Application and Risk Survey
Page 4 of 6
© 2017 Philadelphia Consolidated Holding Corp.
06/2017
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SECTION VII - ABUSE AND MOLESTATION N/A
1.
Does the Applicant’s employment process include verification or 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?
Yes
No
2.
Does the Applicant’s state permit criminal background investigations?
Yes
No
If yes, does the Applicant routinely request and receive such background investigations?
Yes
No
3.
Does the Applicant verify employment-related references?
Yes
No
4.
Does the Applicant conduct a personal interview?
Yes
No
5.
Does the Applicant have written procedures for dealing with sexual abuse?
Yes
No
If yes, attach a copy.
6.
Will any independent contractors have access to children / clients or perform operations
where they will be physically touching another person?
Yes
No
If yes:
a.
Please explain:
b.
Does the Applicant perform background checks on hired independent contractors?
Yes
No
7.
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
8.
Has the Applicant ever had an incident which resulted in an allegation of sexual abuse?
Yes
No
If yes, please describe:
a.
Was a claim made against the Applicant?
Yes
No
b.
Was the case settled?
Yes
No
c.
Was the case taken to trial?
Yes
No
d.
How much money was paid as damages to the victim: $
9.
Regarding coverage for Abuse & Molestation, does the Applicant’s current policy:
Exclude coverage
Limit coverage (please indicate limit): $
Neither exclude or limit coverage
10.
Please indicate age range of clients:
From:
To:
High Intensity Functional Fitness
Application and Risk Survey
Page 5 of 6
© 2017 Philadelphia Consolidated Holding Corp.
06/2017
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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
SE
CTION 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)
High Intensity Functional Fitness
Application and Risk Survey
Page 6 of 6
© 2017 Philadelphia Consolidated Holding Corp.
06/2017
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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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HIGH INTENSITY FUNCTIONAL FITNESS APPLICATION AND RISK SURVEY (Philadelphia Insurance Companies)

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Completed 29 July 2020

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