Fillable ICE ARENA SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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ICE ARENA SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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ICE ARENA SUPPLEMENTAL APPLICATION
SUBMISSION REQUIREMENTS
• Complete ACORD Property, Auto and Umbrella Liability if coverages are requested
• Currently valued insurance company loss runs for the current policy period plus four (4) prior years
• Brochure
• Income statement
• Color photos (interior and exterior)
• Applicant’s liability release waiver
•
• If Abuse coverage is requested a copy of the Applicant’s Sexual Abuse Prevention Policy is required
Copy of Applicant’s Partic
ipant Accident policy
Ice Arena Supplemental
Page 1 of 8
© 2018 Philadelphia Consolidated Holding Corp.
05/2018
SECTION I - GENERAL INFORMATION
Contact Phone:
Applicant Name:
Rink Name:
Mailing Address:
Contact Name:
Web address: www.
Effective Date:
Applicant is:
Franchise Partnership Governmental
SIC Code:
Corporation
Risk Management’s Phone:
Non-profit
FEIN:
Risk Management Contact:
Risk Management Email:
SECTION II - RECEIPTS
ITEMIZED RECEIPTS LESSON RECEIPTS
Food $ Figure skating lessons $
Non-alcoholic beverages $ Group lessons $
Alcoholic beverages $ Hockey lessons $
Pro shop $ Senior hockey leagues $
Competitions $ Other: $
Ice Shows/Events $
TOTAL RECEIPTS
$
Parties $
Vending $
TOTAL RECEIPTS
$
PERCENTAGE FOR SKATING ITEMIZED RECEIPTS FOR SKATING ONLY
League skating % League skating $
Open skating % Open skating $
Months in operation: Skate sharpening/repair $
TOTAL RECEIPTS
$
Clear Application
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SECTION III - RINK SIZE
Length
=
Square feet
Length
=
Square feet
1.
Are participants required to sign a waiver?
Yes
No
If yes,
League
Minor league
Non-league
Groups
Are parents and /or guardians required to sign for minors under age 18?
Yes
No
2.
Yes
No
If yes,
League
Minor league
Non-league
Groups
Limit per accident: $
Does the Applicant have a written incident report procedure in place?
Yes
No
Does the Applicant keep a log of all incidents?
Yes
No
3.
Does the Applicant require an ice rental agreement?
Yes
No
If yes,
Instructors
Leagues
Groups
4.
By state law, what is the maximum capacity of the ice rink at one time:
5.
By state law, what is the ratio of skaters to floor guards: to
6.
Are floor guards required to wear distinctive clothing that visibly represents their authority
on the ice?
Yes
No
7.
Are employees familiar with appropriate evacuation procedures?
Yes
No
8.
Staff:
Number of full-time:
Number of part-time:
Age:
Under 18 years old:
18-25 years old:
Over 25 years old:
9.
Are instructors employees of the rink?
Yes
No
If no, do they furnish certificates of insurance?
Yes
No
10.
Does the Applicant have skate rentals?
Yes
No
If yes, who operates the rental operation?
Applicant
Sub-contractor
If sub-contractor, does the Applicant have a certificate on file as proof of insurance?
Yes
No
11.
Check all that apply:
Shows
Teams
Skating
Contest
Speed skating
Other:
12.
Does the Applicant sponsor any hockey team? If yes, explain:
Yes
No
Are they members of:
USA Hockey
Other:
13.
Do figure skaters utilize the Applicant’s rink/arena?
Yes
No
Are they members of:
USFA
ISI
PSA
Other:
14.
Are rubber mats used in non-skate areas?
Yes
No
How often are they turned:
15.
Does the Applicant have barrier(s) separating skaters from spectators?
Yes
No
If yes, height:
Acrylic?
Yes
No
If yes,
Strutted
Seamless
Wire Mesh
16.
Dash boards?
Yes
No
Netting?
Yes
No
If yes, is it to the ceiling?
Yes
No
How often is the netting maintained:
17.
Hockey goal nets:
Breakaway/rest on surface
Anchored/bolted to surface
18.
Is the ice surface ever covered or removed for other activities? If yes, explain:
Yes
No
If yes, is the seating:
Permanent
Temporary/Portable
Maximum seating capacity:
19. Type of seating:
Yes No
Wood Metal Concrete Other:
Does the seating cause any risk to the spectator at any point?
Does the Applicant use non-slip surface/treads? Yes No
20. Type of ice resurfacing equipment: Age:
Yes No
Yes No
Yes No
Fuel source: Propane Gas Electric Other:
Does the Applicant have a written log of service?
Does the Applicant have a proper draining room for the ice re-surfacing equipment?
Does the Applicant have a written procedure in place to re-surface the ice?
How is ice thickness determined:
Ice Arena Supplemental
Page 2 of 8
© 2018 Philadelphia Consolidated Holding Corp.
05/2018
Does the Applicant maintain a Participant Accident policy?
0
0
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21.
Does the Applicant have Carbon Monoxide Detectors?
Yes
No
If yes:
Battery Operated?
Yes
No
Hard Wired?
Yes
No
22.
What kind of ventilation system does the rink have:
23.
Who is responsible for the maintenance of the ventilation system?
a.
If the insured’s employees, are all maintenance workers who work on the
refrigeration and air conditioning systems properly certified in heating/ventilation/air
conditioning (HVAC) service and repairs?
Yes
No
b.
If a subcontractor, is the sub required to carry at least $1,000,000 of Commercial
General Liability, indemnify/hold the insured harmless and name the insured as an
additional insured on their insurance policy?
Yes
No
24.
What kind of refrigeration system does the rink use:
25.
Who is responsible for maintenance of refrigeration:
a.
If the insured’s employees, are all maintenance workers who work on the
refrigeration and air conditioning systems properly certified in heating/ventilation/air
conditioning (HVAC) service and repairs?
Yes
No
b.
If a subcontractor, is the sub required to carry at least $1,000,000 of Commercial
General Liability, indemnify/hold the insured harmless and name the insured as an
additional insured on their insurance policy?
Yes
No
26.
How long would it take to replace the building and the rink refrigeration system:
27.
How often does the Applicant test air samples:
28.
Who maintains parking lot and curbs during winter storms:
Applicant
Sub-contractor
29.
When a storm occurs, is there a procedure in place to remove ice and snow from the roof
immediately following to avoid roof collapse? If yes, explain:
Yes
No
30.
Does the Applicant have any inflatable, fabric or air supported structures such as, but not
limited to, bubbles or domes?
Yes
No
31.
Does the Applicant operate a babysitting service? If yes, explain:
Yes
No
32.
Is smoking allowed? If yes, explain:
Yes
No
33.
Does the Applicant store flammable cleaning fluids on the premises?
Yes
No
If yes, where are they stored:
34.
If the power goes out, is there emergency lighting?
Yes
No
35.
Does the Applicant have locker rooms?
Yes
No
How are they monitored:
36.
Does the Applicant have shower rooms?
Yes
No
If yes, are they open to the public?
Yes
No
SECTION IV – 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
Ice Arena Supplemental
Page 3 of 8
© 2018 Philadelphia Consolidated Holding Corp.
05/2018
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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 V - FOOD AND BEVERAGES
1.
Who operates the concession?
Applicant
Sub-contractor
2.
Is it self service?
Yes
No
3.
Does the Applicant have designated eating areas?
Yes
No
4.
Cooking equipment?
Electric
Gas
Propane
Other:
5.
Are grills and deep fryers equipped with hoods, automatic fire suppression systems, and
automatic fuel shutoff controls?
Yes
No
6.
How often is the system cleaned:
Monthly
Bi-Monthly
Quarterly
Semi-Annual
Other:
7.
List types of food/beverage sold:
8.
Would the Applicant like a quote for Boiler and Machinery?
Yes
No
Current carrier:
Limits: $
Any claims? If yes, describe.
Yes
No
SECTION VI - ABUSE OR MOLESTATION N/A
A COPY OF THE APPLICANT’S SEXUAL ABUSE PREVENTION POLICY IS REQUIRED
1.
Yes No
Does the Applicant have a written policy specifically defining and prohibiting grooming
behaviors?
If yes:
a. Is this policy communicated and confirmed in writing to all employees, volunteers,
and/ or independent contractors that have access to children? Yes No
b.
Yes No
Does the policy prohibit contact with minor participants outside of the Applicant’s
operations (including social media)?
Comments:
2. Does the Applicant conduct documented sexual abuse awareness training for all of the
following that have access to children?
a. Employees Yes No
b. Volunteers Yes No
c. Independent Contractors Yes No
IF YES, PLEASE SUBMIT A WRITTEN COPY OF THE TRAINING DOCUMENT.
Comments:
Ice Arena Supplemental
Page 4 of 8
© 2018 Philadelphia Consolidated Holding Corp.
05/2018
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3. Does the Applicant specifically train their hiring manager(s) with respect to detecting high
risk behaviors/ responses in the hiring process? Yes No
4. Does the Applicant perform criminal background checks for all:
a. Employees Yes No
b. Volunteers Yes No
c. Yes No Independent Contractors
Comments:
5. In addition to criminal history question(s), does the Applicant’s employment application(s)
for employees, volunteers, and independent contractors contain question(s) to elicit high
risk responses specific to child sexual abuse? Yes No
6.
Yes No
Does the Applicant allow any one-on-one opportunity between employees, volunteers
and/ or independent contractors and the children they serve?
If yes, please describe:
7.
Yes No
Does the Applicant have any operations where employees, volunteers and/ or
independent contractors will be physically touching another person?
If yes, please describe:
8. Does the Applicant have formal sexual abuse reporting procedures in place for all players,
employees, volunteers and/ or independent contractors? Yes No
9. Yes No Has the Applicant ever had an incident which results in an allegation of sexual abuse?
If yes, please describe:
Ice Arena Supplemental
Page 5 of 8
© 2018 Philadelphia Consolidated Holding Corp.
05/2018
Clear Application
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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
SECTION TO B
E 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)
Ice Arena Supplemental
Page 6 of 8
© 2018 Philadelphia Consolidated Holding Corp.
05/2018
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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 t
he 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)
Page 1 of 2
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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 KNO
WINGLY 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 (PLEASE
PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
____________________________________________________
SIGNATURE DATE
SECTION TO BE
COMPLETED BY THE PRODUCER/B
ROKER/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)
Page 2 of 2
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Completed 29 July 2020

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