Fillable Hunting Clubs, Preserves and Shooting Ranges General Liability (RT Specialty)

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Hunting Clubs, Preserves and Shooting Ranges General Liability (RT Specialty)

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  • 16 check-boxes
  • 297 other fields

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Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675 • Fax (480) 483-6752
www.scottsdaleins.com
Hunting Clubs, Preserves and Shooting Ranges General Liability Application
Applicant’s Name:
Mailing Address:
Location Address:
Agency Name:
Agent:
Address:
E-mail:
Phone No.:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
Applicant is: Individual Corporation Partnership Joint Venture
Limited Liability Company Other (Specify):
Website Address:
E-mail Address: Phone Number:
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
Limits of Liability & Deductible Requested:
General Aggregate (other than Products/Completed Operations)
$
Products & Completed Operations Aggregate $
Personal & Advertising Injury (any one person or organization) $
Each Occurrence $
Damage To Premises Rented To You (any one premise) $
Medical Expense (any one person) $
Other Coverages, Restrictions, and/or Endorsements: $
Deductible $
1. Additional Insured Information:
Name Address Interest
GLS-APP-26s (10-13) Page 1 of 6
Submit Application
2. Indicate all operations of applicant:
Archery Range:
Number indoor: Number outdoor: Gross sales:
Hunting Preserve:
For-profit: Not-for-profit: Gross sales:
Private Membership Club:
Type: Number of members:
Rifle or Pistol Range:
Number indoor: Number outdoor: Gross sales:
Skeet or Trap Shooting Range: Number of ranges: Gross sales:
Other (describe): Gross sales:
3. Total number of employees:
4. Does applicant have Workers’ Compensation coverage in force? ...................................................... Yes No
5. Is the applicant a group of landowners or hunt clubs? ......................................................................... Yes No
If yes, explain:
6. Any wilderness or survival camp operations? ....................................................................................... Yes No
7. Total acreage for owned or leased land and lakes:
8. Number of ponds/lakes: Size:
Posted no swimming?.................................................................................................................................. Yes No
9. Dams/levees? ............................................................................................................................................. Yes No
If yes, complete GLS-113 Dam Questionnaire.
10. Any swimming or wading pools? ............................................................................................................ Yes No
If yes:
a. Number of pools:
b. Pool area fenced with self-latching gate? ............................................................................................. Yes No
c. Depths marked? .................................................................................................................................... Yes No
d. Rules posted? ....................................................................................................................................... Yes No
e. Life safety equipment at poolside? ....................................................................................................... Yes No
f. Platforms or diving boards? ................................................. Yes No If yes, height:
g. Slides? .................................................................................. Yes No If yes, height:
h. Lifeguards? ........................................................................................................................................... Yes No
i. Swimming pools, wading pools, hot tubs and spas in compliance with the federal Virginia Braeme
Baker Pool and Spa Safety Act? ...........................................................................................................
Yes No
11. Does applicant have any catering operations? ..................... Yes No If yes, gross sales:
12. Does applicant rent or lease out halls?.................................. Yes No If yes, square feet:
13. Are alcoholic beverages served, provided or sold? ............. Yes No If yes, liquor receipts:
14. Does applicant have a restaurant or concession stand? ..... Yes No If yes, food receipts:
Describe:
15. Overnight lodging? .................................................................................................................................... Yes No
Describe:
Square footage: Number of beds:
GLS-APP-26s (10-13) Page 2 of 6
16. Describe other facilities and buildings:
17. Does risk store LPG, flammable liquids, ammunition or explosives on the premises? .................... Yes No
If yes, type and quantity stored:
18. Number of boats: Number of boats in excess of 26 ft. or with motors over 75 HP:
Are Coast Guard approved flotation devices provided for each passenger? .............................................. Yes No
19. Does applicant require a hold harmless/waiver signed by all participants? ...................................... Yes No
20. What safety controls are in place?
21. Are minors allowed on the premises?..................................................................................................... Yes No
If yes, is it required that they are accompanied by a member and/or parent/guardian at all times? ........... Yes No
22. Does risk lend, lease or rent any equipment to others? ....................................................................... Yes No
If yes, state the type of equipment involved and the gross receipts derived therefrom:
23. Distance from outside operations to nearest populated town:
Distance from outside operations to nearest public road:
24. Does applicant provide firearms? ............................................................................................................ Yes No
25. Merchandise and Services:
Sale of firearms? ......................................................................... Yes No If yes, receipts:
Sale of ammunition/black powder? .............................................................................................................. Yes No
Ammunition reloading? ................................................................................................................................ Yes No
Gunsmithing? ............................................................................................................................................... Yes No
Sale of other items? .................................................................... Yes No If yes, receipts:
Describe other items:
26. Does applicant provide firearms certification/training schools? ......................................................... Yes No
If yes, advise payroll:
27. Number of: Owned ATVs: Owned snowmobiles:
Advise what they are used for:
28. Does applicant provide hunting guides? ........................ Yes No If yes, number of guides:
29. For shooting ranges, are all participants required to wear hearing and eye protection? ................. Yes No
30. For risks with hunting operations:
Do hunters have valid hunting licenses? ..................................................................................................... Yes No
Are hunters required to comply with federal and state hunting laws? ......................................................... Yes No
Number of hunters at any one time:
Number of owned saddle animals used for hunting trips:
Number of owned pack animals used for hunting trips:
Number of stables:
Protections (i.e., posted, fenced, etc.):
GLS-APP-26s (10-13) Page 3 of 6
31. During the past three years, has any company ever canceled, declined or refused to issue simi-
lar insurance to the applicant? (Not applicable in Missouri) ....................................................................
Yes No
If yes, explain:
32. Does risk engage in the generation of power, other than emergency back-up power, for their
own use or sale to power companies?....................................................................................................
Yes No
If yes, describe:
33. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
34. Schedule Of Hazards:
Loc.
No.
Classification Description
Class.
Code
Exposure
Premium Basis
(s) Gross Sales
(p) Payroll
(a) Area
(c) Total Cost
(t) Other
35. Prior Carrier Information:
Year:
Year:
Year:
Carrier
Policy No.
Coverage
Occurrence or Claims Made
Total Premium
36. Loss History:
Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give
rise to claims for the prior three years. Check if no losses last three years.
Date of
Loss
Description of Loss
Amount
Paid
Amount
Reserved
Claim Status
(Open or
Closed)
GLS-APP-26s (10-13) Page 4 of 6
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
FRAUD WARNING: 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. (Not applicable to Oregon).
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation 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 policy holder or claimant for
the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to
an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In
addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any in-
surer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a
felony of the third degree.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be sub-
ject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: 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.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against
an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading infor-
mation is guilty of a felony.
NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents
a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties
under state law.
GLS-APP-26s (10-13) Page 5 of 6
FRAUD WARNING (APPLICABLE IN 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. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
NEW YORK AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for commercial insurance or a statement of claim for any commercial or per-
sonal insurance benefits containing any materially false information, or conceals for the purpose of misleading, infor-
mation concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly
makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, dam-
age or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance
company, 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 value of the subject motor vehicle or stated claim for each violation.
NEW YORK OTHER THAN AUTOMOBILE FRAUD WARNING: 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 also be subject to 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 an active owner, partner or executive officer)
PRODUCER’S SIGNATURE: DATE:
NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT:
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.
GLS-APP-26s (10-13) Page 6 of 6
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Hunting Clubs, Preserves and Shooting Ranges General Liability (RT Specialty)

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Completed 13 December 2020

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