Fillable Hole-In-One Insurance Application (Colonial General Insurance Agency, Inc)

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Hole-In-One Insurance Application (Colonial General Insurance Agency, Inc)

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P.O. Box 14770, Scottsdale, AZ 85267-4770
8475 E. Hartford Dr., Scottsdale, AZ 85255
(480) 991-7889 WATS (800) 848-8860
Fax (480) 948-1394 Toll Free (866) 240-8807
P.O. Box 571770, Murray, UT 84157-1770
5373 S. Green St., Suite 525, Murray, UT 84123
(801) 290-1144 WATS (800) 594-8900
Fax (801) 290-1160 Toll Free (
800) 332-9285
Hole-In-One Insurance Application
Applicant’s Name
Agent’s Name
Mailing Address
Agency Name
Address
Location
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE.”
Applicant is:
Individual Corporation Partnership Joint Venture Other (Specify):
A. Location of Golf Club where tournament is to be held:
B. Title of Tournament:
C. Limit of Liability desired: $
D. Prize will be: Cash Car Other:
E. Date(s) of Coverage:
F. Number of Rounds per day:
G. Number of Participants:
H. How many shots does each participant have at insured hole during tournament play?
I. 9 Hole Course 18 Hole Course
J. Are there more than four par 3 holes on the course? ...........................................................................
Yes No
K. Hole(s) to be covered: No.: Length in yards: Par:
L. If more than one hole, is there a prize per hole?.................................................................................... Yes No
If yes, amount of coverage per hole: $
M. Any losses for specified hole(s) in the past five years? ....................................................................... Yes No
If yes, describe:
Hole must b
e at least 120 yards.
IM-APP-1 (11-06) Page 1 of 2
IT IS HEREBY UNDERSTOOD AND AGREED BY THE APPLICANT THAT:
Coverage is for amateurs only.
Certification of achievement shall be made by one witness, the successful competitor and the Club Secretary.
Persons who will be certifying:
Name/Title
Name/Title
Name/Title
The Hole-In-One must occur during official tour
nament play by an official player.
No practice shots shall be permitted and all shots shall be made in the reg
ular round of tournament play.
Any policy issued will be based upon the above information and will be considered as conditions in the policy.
FRAUD WARNING:
Any person who knowingly and with intent to defraud any insu
rance 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.
FRAUD WARNING (APPLICABLE IN
TENNESSEE AND WASHINGTON):
It is a crime to knowingly provide false, incomplete, or misleadi
ng information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK:
Any person who knowingly and with intent to defraud any insu
rance 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 also be
subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by active owner, partner
or executive officer)
PRODUCER’S SIGNATURE: _______________________________________________________________ DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IOWA LICENSED AGENT:
(Applicable in Iowa Only)
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional
information as to the nature and scope of the report, if one is made, will be provided.
Agent’s E-mail Address____________________ Preferred Method of Correspondence? E-Mail Fax Regular Mail
Applicant’s E-mail Address _________________ Preferred Method of Correspondence
? E-Mail Fax Regular Mail
IM-APP-1 (11-06) Page 2 of 2
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Completed 22 August 2020

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