Fillable LODGE & RESORT APPLICATION (Philadelphia Insurance Companies)

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LODGE & RESORT APPLICATION (Philadelphia Insurance Companies)

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LODGE & RESORT APPLICATION
SUBMISSION REQUIREMENTS
• All brochures describing any and all services; or website address.
• The liability waiver/hold harmless agreement the Applicant requires the Applicant’s 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
Named Insured:
Principal Contact:
Mailing Street Address:
Mailing City: State: Zip:
Location Street Address:
Location City: County: State: Zip:
Phone Number:
Fax Number:
Website: www.
Business Form:
Corporation
Partnership
Individual
LLC
Other:
Effective Date:
Limit of Liability requested:
$ 300,000 Occurrence
$ 500,000 Occurrence
$ 1,000,000 Occurrence
Risk Management Contact:
Risk Management’s Phone:
Risk Management Email:
1.
Does the Applicant 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 Other 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:
TELEPHONE:
E-MAIL:
THIS IS AN APPLICATION FOR INSURANCE. THIS IS NOT A BINDER OF INSURANCE.
Lodge and Resort Application
Page 1 of 10
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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PROPERTY SECTION
N/A
Premises Information
. Distance to fire station? Miles
. Is the responding fire department staffed or volunteer?
. Distant to fire hydrant? Feet
. Are there other fire control water sources available?
Pool Pond/Lake Water Tank Other:
. Are there buildings at the Applicant’s facility with limited access due to forest,
terrain or season?
Yes No
. Are the Applicant’s buildings located in heavily wooded areas? Yes No
. Is the clearing from forest/ wooded areas greater than 150 feet? Yes No
. Is the Applicant’s business operational year round? Yes No
If no, provide the number of months the Applicant is operational? Months 
. Are the Applicant’s buildings occupied year round? Yes No
1. If no, is there a caretaker on site Yes No or contracted? Yes No
1. If no, are buildings winterized? Yes No
Building Information
1. Are there smoke alarms in all corridors and bedrooms? Yes No
2. What types of smoke alarms are installed? Battery Hardwired
3. Is there a CO alarm installed? Yes No
4. Do any buildings have cooking facilities? Yes No
If yes, list building numbers:
5. Do any buildings have wood burning fireplaces and/ or woodstoves? Yes No
If yes, list building numbers:
If yes, are the chimneys and flues cleaned annually? Yes No
6. Do any buildings have any ACTIVE Knob and Tube and/ or Aluminum wiring? Yes No
If yes, list building numbers:
DOCK INFORMATION
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? Yes No
4. Does the water around the Applicant’s dock freeze? Yes No
If yes, what date on average?
5. Are the docks removed? Yes No
ACTIVITIES
Actual Total Receipts for Prior 12 Months:
$
Estimated Total Receipts for Next 12 Months:
$
Activities Conducted
# of Guides
# of Units
User Days
Revenues
Guided Fishing
$
Hiking/ Backpacking
$
Hunting
$
Lodging/ Cabin Rentals
$
Horseback Riding
$
Hay, Sleigh or Wagon Rides
$
Lodge and Resort Application
Page 2 of 10
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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# of Guides
# of Units
User Days
Revenues
Shooting Range – Rifle or Pistol
$
Bike Rentals
$
Mountain Bike Riding
$
Boating
$
Sea Kayak Tours/ Rentals
$
Water skiing
$
Jet Skis or Wave Runners
$
River Tubing
$
Whitewater Rafting
$
Cross Country Skiing
$
Dog Sled Tours
$
Downhill Skiing
$
ATV’s
$
Snowmobiles
$
Paintball
$
Climbing Wall
$
Rock Climbing
$
Youth Camps or Programs
$
Other describe:
$
OPERATIONS INFORMATION
1.
Does the Applicant require the Applicant’s guests to sign a liability waiver?
Yes
No
2.
How many years has the Applicant been in business?
Years
3.
If the Applicant is a new venture, how many years of prior experience?
Years
4.
Are any operations conducted outside of the United States?
Yes
No
5.
Does the Applicant hire guides as sub-contractors?
Yes
No
If yes, for what activities?
If yes, does the Applicant obtain proof of insurance?
Yes
No
6.
List safety procedures and/ or attach safety guidelines:
LODGING
N/A
Guest Quarters
1.
Total number of units for guest rental:
2.
Number of RV spaces/ tent sites:
3.
Maximum guest capacity is:
KITCHEN OPERATIONS
N/A
1.
Does the Applicant have an automatic extinguishing system over the cooking
surface?
Yes
No
2.
Does the Applicant have automatic fuel shut-off to stove?
Yes
No
3.
Is there a maintenance contract to clean the Applicant’s duct system?
Yes
No
4.
Does the Applicant have one or more fire extinguishers?
Yes
No
5.
Does the Applicant have any deep fat fryers?
Yes
No
6.
Is there a restaurant, bar or lounge on the premises?
Yes
No
If yes, is it open to the general public?
Yes
No
7.
What are the Applicant’s liquor sales?
$
8.
What are the Applicant’s restaurant sales, not including liquor?
$
9.
Of restaurant & liquor sales, what percentage is from people NOT lodging at the
resort?
%
10.
What is the restaurant seating capacity?
Activities Conducted
Lodge and Resort Application
Page 3 of 10
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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SERVICE OPERATIONS
N/A
1.
Does the Applicant host any of the below events?
Annual Revenues
Weddings
Yes
No
$
Conferences
Yes
No
$
Special Events, describe:
Yes
No
$
2.
Does the Applicant provide the catering at these functions?
Yes
No
3.
Does the Applicant provide the liquor at these functions?
Yes
No
If no, does the Applicant collect certificates from the caterers that work on the
Applicant’s premise?
Yes
No
If the Applicant is requesting Liquor Liability the Applicant must complete the Liquor Liability
Supplemental Application
RETAIL OPERATIONS
N/A
1.
Does the Applicant have retail operations for any of the following?
General Store
Pro Shop
Restaurant
Liquor Store
Gift Shop
Fuel Sales
2.
What are the Applicant’s total gross sales from retail operations?
$
POOL AND SWIMMING AREAS
N/A
1.
How many of each: Pools Lakes Other:
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
2.
Are the Applicant’s swimming facilities open to the general public?
Yes
No
3.
Fenced?
Yes
No
4.
Diving board?
Yes
No
5.
Locking gate?
Yes
No
6.
Is the depth of pool marked?
Yes
No
7.
Are life rings or buoys provided?
Yes
No
8.
Life guard on duty?
Yes
No
9.
Pool rules posted?
Yes
No
10.
Is there signage “No life guard, swim at your own risk, no diving”?
Yes
No
11.
Does the Applicant have a water tramp?
Yes
No
12.
Does the Applicant have a waterslide?
Yes
No
If yes, what is the length & height of slide? Length: / Height:
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
WATERCRAFT GENERAL INFORMATION
1.
What type of operation does the Applicant have?
Boat Rentals
Fishing Trips
Tube or Canoe Rentals
Hunting
Other:
2.
On what bodies of water does use take place?
Rivers
Lakes
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
Lodge and Resort Application
Page 4 of 10
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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CANOE, KAYAK AND/ OR RIVER TUBING INFORMATION
N/A
Boat Type
Maximum Number Used
Average Number Used
Canoes
Kayaks
Tubes
1.
What percent of the Applicant's operations are unguided?
%
2.
Number of guides:
EQUINE SECTION
N/A
Ride Information
1.
Total number of horses available for guest riding:
2.
Maximum number of horses in use for guest riding at any one time:
3.
Average number of horses in use for guest riding at any one time:
4.
What is the youngest rider the Applicant will allow on a horse:
Years Old
5.
Does the Applicant offer the use of helmets?
Yes No
6.
Does the Applicant ever allow double riding?
Yes No
7.
What percentage of the Applicant’s guest ride: Western Saddle?
% vs. English Saddle? %
8.
What percentage of the Applicant's horse operations are: Unguided? % vs. Guided? %
9.
What is the maximum guide to guest ratio? Guides to
Guests
10.
Does the Applicant operate pony rides?
Yes
No
If yes:
Trail Ride
Riding Ring
Hand Led
11.
What is the youngest rider the Applicant will allow on a pony?
Years Old
12.
Does the Applicant require guest to complete a physical fitness information form
prior to riding?
Yes No
13.
Does the Applicant pre-screen guest riders and determine ability prior to riding?
Yes No
14.
Do guides carry with them any communication device (2-way radio, cell phone, etc.?)
Yes No
15.
Does the Applicant conduct a pre-ride safety briefing with guests?
Yes No
16.
Does the Applicant provide a written safety manual of procedures to all staff
members?
Yes No
17.
Does the Applicant ever participate in parades or community celebrations with the
Applicant’s horses?
Yes No
18.
Lists reasons why the Applicant would decline a person from riding (health, age,
weight, alcohol, general, pregnancy):
ACCOUNT INFORMATION
1.
Does the Applicant board horses for a fee?
Yes
No
If yes, how many?
2.
Does the Applicant teach or allow the Applicant’s guests to participate in:
Dressage
Inoculations
Barrel Racing
Horse Jumping
Horse Racing
Team Penning
Hay Rides
Roping Cattle
Cattle Drives
Sleigh Rides
Branding Cattle
Handling Livestock
Buckboard/ Buggy Rides
3.
Are guests allowed to handle rope or brand livestock?
Yes
No
4.
If the Applicant conducts Cattle Drives, what is the number of:
Wranglers to Riders Maximum Duration: Maximum Distance:
5.
If the Applicant’s ranch conducts a Rodeo/ Gymkana, describe what activities the Applicant’s
guests can participate in:
GUIDE INFORMATION
Name
Age
Years Experience
First Aid Qualifications
Lodge and Resort Application
Page 5 of 10
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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LOSS HISTORY
Date
Description of Incident
Amount Paid/Reserved
$
$
$
1.
Does the Applicant have knowledge of any incident which may lead to a claim?
Yes
No
If yes, please describe:
AUTOMOBILE
1.
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
2.
How often does the Applicant check MVR reports?
3.
Does the Applicant allow any newly hired drivers to operate vehicles without
going through a company-specific documented driver training?
Yes No
4.
Describe any ongoing training provided to drivers:
5.
Does the Applicant have GPS tracking capability?
Yes No
6.
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
Lodge and Resort Application
Page 6 of 10
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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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:
Lodge and Resort Application
Page 7 of 10
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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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 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)
Lodge and Resort Application
Page 8 of 10
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02/2019
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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 alleg
ing 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
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
SECT
ION 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)
PI-CYBE-APP (11/16)
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LODGE & RESORT APPLICATION (Philadelphia Insurance Companies)

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Completed 29 July 2020

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