Fillable HUNTING PRESERVE APPLICATION - FLORIDA (Philadelphia Insurance Companies)

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HUNTING PRESERVE APPLICATION - FLORIDA (Philadelphia Insurance Companies)

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HUNTING PRESERVE APPLICATION - FLORIDA
SUBMISSION REQUIREMENTS
• All brochures describing any and all services; or website address.
• 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. Do you operate any other businesses 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
PRODUCING INSURANCE AGENT
AGENCY:
CONTACT:
ADDRESS:
TELEPHONE: FAX:
E-MAIL:
THIS IS AN APPLICATION FOR INSURANCE. THIS IS NOT A BINDER OF INSURANCE.
State: Zip:
County: Zip: State:
Fax Number:
Risk Management’s Phone:
Partnership Individual LLC Other:
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 Form: Corporation
Effective Date:
Limit of Liability Requested: $ 300,000 Occurrence
$ 500,000 Occurrence
$ 1,000,000 Occurrence
Hunting Preserve Application - Florida
Page 1 of 8
© 2018 Philadelphia Consolidated Holding Corp.
11/2018
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Premises Information
1.
Is your location within 50 miles of the Gulf of Mexico or the Atlantic Oc
ean?
2.
What is the Fire Protection Class of your location?
3.
Distance to fire s
tation?
M
iles
4.
Is the responding fire department
s
taffed or
volunteer?
5.
Distant to fire h
ydrant?
F
eet
6.
Are there other fire control water sources available?
Pool
Pond/Lake
Water Tank
Other:
7.
Is your location prone to grass fires and/or forest fires?
No
8.
Are there buildings at your facility with limited access due to forest, t
errain or
season?
No
9.
Are your buildings located in heavily wooded areas?
No
10.
Is the clearing from forest/wooded areas greater than 150 feet?
No
11.
Is your business operational year round?
No
If no, provide the number o
f months you are operational?
Months
12.
Are your buildings occupied year round?
No
13.
If no, is there a caretaker on site
Yes
No
or contracted?
No
14.
If no, are buildings winterized?
Building Information
1.
Are there smoke alarms in all corridors and bedrooms?
No
2.
What type of smoke alarms are installed?
Battery
Hardwired
3.
Is there a CO alarm installed?
No
4.
Do any buildings have cooking facilities?
No
If yes, list building numbers:
5.
Do any buildings have wood burning fireplaces and/ or woodstoves?
No
If yes, list building numbers:
If yes, are the chimneys and flues cleaned annually?
No
6.
Do any buildings have any ACTIVE Knob & Tube and/
or Aluminum wiring?
No
If yes, list building numbers:
7.
Do you have power generating equipment?
No
If yes, is it 100% for emergency use only?
Yes
No
List the size of each (HP & KW):
1.
Number of docks:
2.
Number of boat slips:
Complete the questions below only if property coverage is requested for docks.
3.
Construction:
Frame
Metal
Floating
Fixed Roofed
Age
If roofed, has proper engineering for wind/ snow loads been assessed?
No
4.
Does the water around your dock freeze?
No
If yes, what date on average:
5.
Are the docks removed?
No
ACTIVITIES SECTION
Activities Conducted
Number of Guides
Number of Units
Club Members
Members
Acreage
-
Leased
Acres
Acreage
-Owned
Acres
Archery Range
Stations
Range (Rifle & Pistol)
–
indoor
Lanes
Range (Rifle & Pistol)
–
outdoor
Lanes
Sporting Clay
No
PROPERTY SECTION
N/A
DOCK INFORMATION
No
Hunting Preserve Application - Florida
Page 2 of 8
© 2018 Philadelphia Consolidated Holding Corp.
11/2018
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Activities Conducted Number of Guides Number of Units
Trap & Skeet
Big Game Hunting
Upland Bird Hunting
Waterfowl Hunting
Lakes or Ponds
Boats
Farming: Crops, Livestock $ Revenues
Clubhouse Square Feet
Lodging Rooms
Restaurant
Liquor Sales
Retail Store
Docks & Piers
ATV-guided
ATV-unguided
Youth Programs
1. Check all that apply to your operation:
For Profit Not-for-Profit Open to Public Private Membership
2. Do you require participants to sign a liability waiver? Yes No
3. How many years have you been operating? Years
4. If you are a new venture, how many years of prior experience? Years
5. Are any operations conducted outside of the United States? Yes No
6. Do you hire guides as sub-contractors? Yes No
If yes, for what activities?
If yes, do you obtain proof of insurance? Yes No
7. List safety procedures and/or attach safety guidelines:
CLUBHOUSE/LODGING SECTION N/A
1. Total number of units/rooms for lodging?
2. What is the square footage of the main lodge or clubhouse? Square Feet
3. Number of RV spaces/Tent sites:
4. Maximum guest capacity is:
5. Do you have a swimming pool or swimming area? Yes No
If yes, do you have a diving board? Yes No
6. 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
SPECIAL EVENT / DOG TRIAL SECTION N/A
1. Special Events
Number of Events:
Type of Event(s):
Revenue:$
2. Number of
Participants:
Spectators:
Volunteers:
3. How many field trial events are held annually?
4. What is the minimum age of a volunteer gunner – bird boy? Years
Hunting Preserve Application - Florida
Page 3 of 8
© 2018 Philadelphia Consolidated Holding Corp.
11/2018
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HUNTING SECTION N/A
1. What percentage of your hunting operations are unguided? %
2. What type of game is being hunted?
Elk Deer Exotics Bear Turkey Upland Birds
Hogs Alligators Waterfowl Other:
3. Are Tree Stands used? Yes No
4. Do you use any of the following to transport hunters? If yes, how many?
ATV’s:
Horses:
Snowmobiles:
Boats:
Other Unlicensed Vehicles:
EXPOSURE INFORMATION
Use of helmets on ATV’s is mandatory frequent rare nonexistent N/A
Use of muzzleloaders is frequent rare nonexistent prohibited
Use of pistols is frequent rare nonexistent prohibited
Use of modified weapons is frequent rare nonexistent prohibited
Tree stand use is frequent rare nonexistent
Tree stand safety harness use is mandatory frequent rare nonexistent
frequent rare nonexistent Heavy Equipment use is
(Tractors, bulldozers, etc.)
ATV, Hunting Buggy, Argo use is frequent rare nonexistent
Snowmobile use is frequent rare nonexistent
Sponsored youth events are frequent rare nonexistent
Members sign liability waivers mandatory frequent rare nonexistent N/A
Guests sign liability waivers mandatory frequent rare nonexistent N/A
Clients sign liability waivers mandatory frequent rare nonexistent N/A
SHOOTING RANGE SECTION N/A
1. Is a rangemaster / supervisor on premise during shooting hours? Yes No
2. What is the minimum age of an unsupervised shooter? Years Old
3. Is the premise secured and locked when not operating? Yes No
4. Are range rules and safety guidelines posted in a conspicuous manner? Yes No
5. What is the maximum distance of ranges? Yards
6. What type and kind of backstop or berm is used?
Describe:
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
Hunting Preserve Application - Florida
Page 4 of 8
© 2018 Philadelphia Consolidated Holding Corp.
11/2018
Clear Application
Print Application
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WATERCRAFT GENERAL INFORMATION
1. How are boats used?
Boat Rental Fishing Hunting Other, describe:
2. On what bodies of water does use take place?
Rivers Lakes/Ponds 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
GUIDE INFORMATION SECTION N/A
Name Age Years Experience First Aid Qualifications
SALES AND REVENUE SECTION N/A
Sales Information
1. Do you raise game birds for sale to others? Yes No
2. Do you sell game birds to restaurants or to other food processors? Yes No
3. Do you sell handguns? Yes No
How many a year? handguns
4. Do you sell used guns? Yes No
How many a year? used guns
GROSS RECEIPTS
Actual Total Receipts for Prior 12 Months:
$
Estimated Total Receipts for Next 12 Months:
$
Membership Dues $
Rifle/Pistol Range $
Shotgun Range/Trap & Skeet $
Pro-Shop or Retail Operations $
Of this amount, how much is gun sales? $
Restaurant Sales $
Of this amount, how much is liquor sales? $
Lodging $
Gunsmithing $
Game Bird Sales to Others (preserves, restaurants, etc.) $
Other: $
LOSS HISTORY
Date Description of Incident Amount Paid/Reserved
$
$
$
1. Do you have knowledge of any incident which may lead to a claim? Yes No
If yes, describe:
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Hunting Preserve Application - Florida
Page 5 of 8
© 2018 Philadelphia Consolidated Holding Corp.
11/2018
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FRAUD NOTICE STATEMENTS
APPLICABLE IN FLORIDA: 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).
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
.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR
EXECUTIVE DIRECTOR)
____________________________________________________
SIGNATURE DATE
Produced By: (Section to be completed by Producer/Broker)
PRODUCER AGENCY
PRODUCER LICENSE NUMBER AGENCY TAXPAYER ID OR SS NUMBER
ADDRESS (STREET, CITY, STATE, ZIP)
Hunting Preserve Application - Florida
Page 6 of 8
© 2018 Philadelphia Consolidated Holding Corp.
11/2018
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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 alle
ging 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 WH
O 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.
NAME (P
LEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
____________________________________________________
SIGNATURE DATE
SECTION T
O BE COMPLETED BY THE PRODUCE
R/BROKER/AGENT
PRODUCER AG
ENCY
(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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