Fillable LAND CONSERVANCY APPLICATION (Philadelphia Insurance Companies)

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LAND CONSERVANCY APPLICATION (Philadelphia Insurance Companies)

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LAND CONSERVANCY APPLICATION
SUBMISSION REQUIREMENTS
• ACORD Applications
• The liability waiver/ hold harmless agreement the
• Schedule of vehicles
Applicant requires guests to sign, if applicable
• Currently valued company loss runs for the current
• Drivers list with license numbers/ dates of birth
policy period plus four (4) prior years
• Conservation Application
SECTION I – GENERAL APPLICATION INFORMATION
Applicant Name:
Mailing Address:
Website Address:
Email:
FEIN:
For Profit
Non Profit
Year business was established:
Under present management:
Number of Board Members:
State Unemployment ID Number:
Annual operating budget: $
Annual payroll: $
Primary Funding:
Federal
State
County
Other:
List all individual programs:
Description of Applicant’s operations/ mission:
Have there been any claims that allege negligence or failure to comply with any regulatory/
licensing guidelines?
Yes
No
Indicate whether the Applicant’s organization or programs provide the following services
(check all that apply):
Academic or Vocational School
Land Trust Alliance
Residential/ Dormitory
Ameri-Corps
Landscaping
Youthworks Program
Has the Applicant discontinued any programs in the past 5 years?
Yes
No
If yes, explain:
Risk Management Contact:
Risk Management’s Phone:
Risk Management Email:
SECTION II – MANAGEMENT PRACTICES / HIRING / STAFFING
Type of security provided for the protection of the Applicant’s premises or property:
Guards
Video Cameras
Other:
What precautions does the Applicant take to prevent non-staff members from accessing
unauthorized areas of the property or project?
Does the Applicant have incident reporting procedures?
Yes
No
Is the Applicant’s staff made aware of reporting procedures?
Yes
No
Does the Applicant have a plan for medical emergencies?
Yes
No
Is there always someone trained in CPR and first aid on the premises or projects?
Yes
No
Does the Applicant have first aid kits on field projects?
Yes
No
Does the Applicant have a written and enforced no smoking policy?
Yes
No
Are “no smoking” signs posted in all areas not designated for smoking?
Yes
No
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Hiring Practices:
Does the Applicant require staff (paid and volunteer) to complete an employment application?
Yes
No
If no, explain:
Does the Applicant conduct a personal interview for each prospective staff or corps member?
Yes
No
Does the Applicant verify education references?
Yes
No
Does the Applicant verify employment related references?
Yes
No
Does the Applicant verify licenses and other credentials?
Yes
No
Does the Applicant require drug tests on all staff members, including drivers?
Yes
No
If yes:
Before hiring
After hiring
Random
What actions does the Applicant take if any report is considered unfavorable?
Does the Applicant share written job descriptions with all staff members?
Yes
No
Name of executive director:
Number of years at this facility:
Number of years’ experience in this field:
Specialized training or education:
Are any staff/ members under 18 years of age?
Yes
No
If yes, list their position(s) and how they are supervised:
Does the Applicant provide workers compensation for all staff members?
Yes
No
Is the staff required to report to the administrator all incidences that may result in a claim?
Yes
No
If yes, is a written record kept?
Yes
No
Are they reviewed?
Yes
No
Are files maintained to protect confidentiality of clients?
Yes
No
Does the Applicant act as a General Contractor on projects?
Yes
No
If yes, explain:
Annual sub-contracting cost: $
Type of work sub-contracted out:
Are there written agreements with independent contractors?
Yes
No
Are certificates of liability insurance obtained and maintained for all contracted services providers
(independent contractors)?
Yes
No
Please indicate the limits of liability: $
What services are performed by independent contractors?
Does the Applicant do any consulting work?
Yes
No
If yes, explain:
28 Does the Applicant’s current insurance program provide professional liability coverage? Yes No
Staff
Total number of: Full Time (FT) Employees: Part Time (PT) Employees: Volunteers (Vol):
Number of
Employees
Number of
Contracted
Total Annual
Payroll
Number of
Volunteers
Annual
Volunteer
Hours Worked
FT PT FT PT
Counselors – Youth Mentors $
Ameri-Corps Members $
Tour Guides $
Field Survey Staff $
Teachers – Academic $
Teachers – Vocational $
Conservation/ Landscapers
work on trails or open space
$
Conservation/ Landscapers
work on buildings or structures
$
*Other (describe): $
*Other (describe): $
*Please describe “other” professional staff not listed in the above chart in the provided area.
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SECTION III – ABUSE AND MOLESTATION
Does the Applicant’s current insurance program include Abuse and Molestation coverage?
Yes
No
If yes, Occurrence or Claims Made – Retro Date:
Limit of Liability: $
Carrier:
Effective Date:
Does the Applicant’s employment process include verification of 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
Does the Applicant have a written crisis plan in place for dealing with employees, victims,
parents, authorities, and the media if the Applicant has incident of abuse?
Yes
No
Does the Applicant have written procedures for dealing with sexual abuse?
Yes
No
Is there a written supervision plan that monitors staff in day-to-day relationships with staff, both
on and off premises?
Yes
No
Are formal written procedures in place for hiring?
Yes
No
Do volunteers work directly with staff?
Yes
No
Is there formal staff training on child/ sexual abuse, including how to recognize the signs?
Yes
No
What procedures are in place to make sure no relationship occurs between staff and members?
Are there procedures prohibiting closed door one-on-one meetings?
Yes
No
Have any incidents resulted in an allegation of sexual abuse?
Yes
No
Was the case settled?
Yes
No
Was the case taken to trial?
Yes
No
Amount paid for damages to the victim: $
Does the Applicant run criminal background checks on volunteers BEFORE hiring?
Yes
No
If no, do volunteers work directly with any youth?
Yes
No
SECTION IV – PROPERTY/ PREMISES/ LIFE SAFETY/ EXTERNAL EXPOSURES
Number of buildings:
Type of construction:
Number of stories:
Are there sprinklers?
Yes
No
Smoke detectors:
Battery
Hardwired
If battery, is there a regular inspection and replacement procedure?
Yes
No
Are carbon monoxide detectors provided (where warranted)?
Yes
No
Are extinguishers provided?
Yes
No
Is there a regular inspection and replacement procedure?
Yes
No
Is the fire alarm:
Local
Central Station
Manual
Automatic
Does the Applicant have emergency lighting or backup generators in the event of a power
failure?
Yes
No
Are all exits clearly marked and illuminated?
Yes
No
Does the Applicant have a written emergency evacuation plan?
Yes
No
If yes, are there emergency evacuation procedures and floor plan posted?
Yes
No
How often are drills held?
Does the Applicant have a disaster recovery plan in place?
Yes
No
Is there adequate lighting in the parking area?
Yes
No
Are security guards / patrols used?
Yes
No
If yes, are guards:
Armed
Unarmed
Employed
Sub-contracted
Off duty police
Are guards used:
24 hours
Evenings
Other:
Annual payroll/ cost for security patrol: $
Is crime and vandalism in neighborhood:
High
Medium
Low
Does the Applicant have any plans for renovations or new construction?
Yes
No
If yes, explain:
Does the Applicant have a formal maintenance housekeeping program in place?
Yes
No
Does the property have aluminum wiring?
Yes
No
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External Exposures
19.
Is property located in known flood zone?
Yes
No
20.
Does the Applicant have a current flood program policy in force?
Yes
No
If yes, attach a copy of the declaration page.
Yes
No
If no, would the Applicant be interested in a flood quote (additional information will be needed to
obtain a quote)?
Yes
No
21.
Is property located in a known brush/ wildfire area?
Yes
No
22.
Is the property located in close proximity to an Earthquake fault?
Yes
No
SECTION V – FACILITIES AND ACTIVITIES
Please check all applicable facilities and activities associated with the camp:
Aircraft (Flying)
Circus Activities
Off Road Bikes (Motorized)
Skateboarding (ramps /
jumps)
Adventure Program
Cross Country Skiing
Alpine Skiing
Dams
Paintball
Skin or Scuba Diving
Archery
Gymnastics
Picnic Grounds
Trails
ATV’s
Horse Back Riding
Play Facilities
Trampolines
Backpacking
Ice Skating
Rafting
Tubing
Bicycling
Kayaking
Rifle Ranges
Water Skiing
Bridges
Lake or Ponds
Rock Climbing/ Rappelling
Waterslides over 15’ high
Caving
Lodging Facilities
Zip Line
Whitewater Canoeing
Other:
1.
Is ice skating done on a
rink and/ or
lake/ pond?
Are warning signs posted?
Yes
No
2.
Are NRA standards met with all rifle ranges?
Yes
No
3.
Total number of Dams:
List dams on owned or managed lands:
a.
Height:
Age:
Construction:
Spillway:
b.
Height:
Age:
Construction:
Spillway:
Note: Downstream exposure is excluded
4.
Total number of Bridges: #
List bridges (including footbridges) on the Applicant’s land:
a.
Length:
Width:
Height:
Age:
Construction:
b.
Length:
Width:
Height:
Age:
Construction:
5.
If any of the following activities apply, a supplemental application/ questionnaire is required with this
submission:
Fireworks
Go-carts
Paintball
Rock Climbing
Water Trampolines #
SECTION VI – LAND / TRAILS / LAKES / PONDS
Land/Trails
1.
How many acres of land is the property on?
2.
How many trails does the Applicant:
Own:
Approximate no. of miles:
Average width:
Hold easements on:
Approximate no. of miles:
Average width:
Manage under contract:
Approximate no. of miles:
Average width:
3.
Are trails (if listed above) included in the number of acres listed above?
Yes
No
4.
How is land (or trails) used?
5.
How is access to the Applicant’s land (or trails) controlled?
6.
Hours of operation:
7.
Estimated annual receipts: $
Number of visitors per years:
Lakes/Ponds
1.
Does the public have access to the lake area?
Yes
No
2.
Are there boat docks?
Yes
No
If yes, where?
3.
If swimming is allowed, is there a lifeguard on duty?
Yes
No
If yes, during what hours?
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4.
Lake use (check all that apply):
Canoes
Ice Skating
Power Boats*
Swimming
Fishing
Jet Skis
Row Boats
Water Skiing
Ice Fishing
Paddle Boats
Sail Boats
*Maximum horse power and length allowed:
5.
Owned Watercraft (List all owned watercraft)
Total number of watercraft:
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
6.
Non-Owned Watercraft – Describe usage of any non-owned watercraft greater than 55 feet long:
7. Is there watercraft rental? Yes No
If yes, what types? Annual receipts: $
8. Are there separate and designated usage areas? Yes No
9. Is the lake/ pond susceptible to freezing? Yes No
SECTION VII – OVERNIGHT PROJECTS
1. Is written permission/ waiver of liability obtained from every participant under age 18? Yes No
2. What is the average length of stay or project?
Average number of days per project: Number of staff at each project:
Average number of participants per day:
3. Number of staff members at each camp:
4. Are sleeping quarters co-ed? Yes No
5. Are restrooms/ showers co-ed? Yes No
6. Indicate and describe if any of the following exposures exists in the camp projects:
Invasive species removal Landscaping Survey Trail maintenance
7. Does the Applicant host field trips? Yes No
If yes, please explain:
8. What dormitory or residential provisions are provided to the staff/ members:
SECTION VIII – SPECIAL EVENTS
1. List all special events conducted by the Applicant’s organization:
a. Event name: Date(s): Time: Attendance:
Description:
b. Event name: Date(s): Time: Attendance:
Description:
c. Event name: Date(s): Time: Attendance:
Description:
2. Will liquor be served? Yes No
If yes, who will serve it:
Applicant’s employees/
volunteers
Company hired for
event
Individual hired
for the event
Provided without separate
charge
3. Will the Applicant charge admission to the event? Yes No
4. Is a permit required for this event? Yes No
If yes, what kind:
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5.
Will entry forms or waivers be signed?
Yes
No
If yes, attach a copy.
6.
Will volunteers be used?
Yes
No
If yes, in what capacity?
7.
Will the Applicant require an additional insured be added for coverage?
Yes
No
If yes, attach a copy of Applicant’s contract.
8.
List Educational programs conducted by the Applicant’s organization:
a.
Program name:
Date(s):
# of hours:
Attendance:
Description:
b.
Program name:
Date(s):
# of hours:
Attendance:
Description:
c.
Program name:
Date(s):
# of hours:
Attendance:
Description:
SECTION IX – AUTOMOBILE AND DRIVERS
1.
Where does the Applicant keep owned vehicles?
Garage
Driveway
Parking Lot
Other:
2.
Are keys locked and secured away from non-drivers when not in use?
Yes
No
3.
Are vehicles with eight or more seating capacity equipped with an audible backup warning
device?
Yes
No
4.
Does the Applicant provide transportation for volunteers or participants?
Yes
No
If yes, is more than one staff member required in the vehicles?
Yes
No
5.
Does the Applicant transport staff to projects?
Yes
No
If yes, how many employees per vehicle:
6.
Does the Applicant obtain a written authorization from new hire (driver) to release their driver
information PRIOR to hiring?
Yes
No
7.
Does the Applicant have a formal Accident Review Committee that reviews each driver’s
accidents or violations?
Yes
No
8.
Do any employee drivers transport customers that are not employees?
Yes
No
If yes, how often does this take place?
9.
Does the Applicant contract out any driving services to third-parties?
Yes
No
10.
Does anyone besides employees drive the Applicant’s vehicles?
Yes
No
If yes, explain;
11. Does the Applicant have a formal driving policy in place with MVR standards? Yes No
If yes:
a. Is driving policy communicated in writing to all employees? Yes No
b. Is a signed acknowledgement form kept on file? Yes No
If yes, please provide a copy of signed acknowledgement.
c. Do driving standards include the following:
i. No major violations including DUI, racing, hit and run, speeding in excess of 20 mph
over posted speed limit, manslaughter?
Yes No
ii. No more than 2 moving violations within past 3 years? Yes No
iii. No more than 1 at fault accident within past 3 years? Yes No
12. How often does the Applicant check MVR reports?
13. Does the Applicant allow any newly hired drivers to operate vehicles without going through a
company-specific documented driver training?
Yes No
14. Describe any ongoing training provided to drivers:
15. Does the Applicant have GPS tracking capability? Yes No
16. Does the Applicant allow employees to drive personal vehicles for company purposes? Yes No
If yes:
a. Are the driving policy and standards for these drivers the same as in questions 1-3? Yes No
b. Does the Applicant require these employees to have adequate personal insurance limits? Yes No
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SECTION X – HIRED AND NON-OWNED VEHICLES
1.
Does the Applicant use BLM or NFS vehicles?
Yes
No
If yes, how many BLM?
If yes, how many NFS?
2.
Does the Applicant hire vehicles?
Yes
No
If yes, what types of vehicles does the Applicant hire?
Does the Applicant rent or lease vehicles from Enterprise rental program?
Yes
No
3.
Total number of Enterprise vehicles:
Annual cost of hire other than Enterprise: $
SECTION XI – ADDITIONAL INSUREDS AND SUB-CONTRACTOR INFORMATION
ADDITIONAL INSUREDS (if necessary use another sheet of paper)
Name
Complete Address
Interest
1.
Does the Applicant carry workers compensation insurance on its employees and volunteers?
Yes
No
2.
Does the Applicant use sub-contractors in its business?
Yes
No
3.
Does the Applicant always obtain certificates of insurance from sub-contractors?
Yes
No
If yes, what are the minimum General Liability Limits the Applicant requires?
Per occurrence: $
Products and completed operations aggregate: $
General aggregate: $
4.
Does the Applicant require all sub-contractors to name them as additional insured?
Yes
No
5.
Does the Applicant have a standard formal written contract in place with its contractors?
Yes
No
If yes, does the agreement contain an indemnification / hold harmless clause in the Applicant’s
favor?
Yes
No
6.
How long does the Applicant maintain records of subcontractor documents noted above?
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WINTER WEATHER FREEZE-UP PROTECTION
1. Fire Protection and Testing
a. Is the building provided with an Automatic Fire Sprinkler System (AS)? Yes No N/A
i. If yes, approximately what percentage (%) of the building is sprinklered? %
ii. If yes, what type of sprinkler system is installed? Wet-Pipe Dry-Pipe Both
iii. If yes, when possible, is the sprinkler piping primarily run within conditioned
areas designed to ensure the temperature remains above the 45°F minimum
Yes No N/A
iv. If yes, is the testing & inspection by qualified sprinkler contractor completed
within past 12 months & includes a formal winterizatio
n review?
Yes
No
N/A
v. If yes, are the alarms tied to a 24 hour UL listed monitoring company?
Yes
No
N/A
2. Emergency Water Response (domestic and AS water lines)
a. Are water shutoff valves (domestic and AS water lines) marked and readily
accessible?
Yes
No
N/A
b. Are water shutoff valves exercised (closed and reopened) at least annually?
Yes
No
N/A
c. Is the staff qualified to respond and shut off the water main during normal business
hours and off hours?
Yes
No
N/A
3. Automatic Water Shutoff Devices
a. For domestic water lines, is there a water flow detection, notification and automatic
shutoff?
Yes
No
N/A
4. Unused/Vacant Spaces
a. Does Applicant have a formal process to turn off and drain domestic water lines for
these spaces?
Yes
No
N/A
5. Unheated Areas (attics, crawl spaces, exterior wall joists)
a. Are all domestic water lines located in areas heated to at least 45°F?
Yes
No
N/A
i. If no, please describe freeze prevention measures (e.g. temperature monitoring,
heat trace, full insulation):
This section must be completed by all risks that have a location in one of the following states: AR, CT, DC, DE,
GA, IL, IN, KY, ME, MD, MA, MI, MO, NH, NY, NJ, NC, OH, PA, RI, SC, TN, TX, VT, VA, WV, WI
temperature?
1. If no, please describe freeze prevention measures (
e.g. temperature
moni
toring, heat trace, full insulation on piping or roof):
6.
General Comments:
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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
SEC
TION 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)
Land Conservancy Application
Page 9 of 9
© 2019 Philadelphia Consolidated Holding Corp.
05/2019
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LAND CONSERVANCY APPLICATION (Philadelphia Insurance Companies)

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Completed 29 July 2020

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