Fillable MEDIA LIABILITY COVER PRO APPLICATION (Philadelphia Insurance Companies)

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MEDIA LIABILITY COVER PRO APPLICATION (Philadelphia Insurance Companies)

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Application – Media Liability
Page 1 of 10
MEDIA LIABILITY COVER PRO
SM
APPLICATION
Author – Broadcaster – Cablecaster – Online Content – Publisher – Special Appearance
NOTICE: This Media Liability coverage may be provided on an occurrence or claims-made basis.
If coverage is requested for Film and Program Production or for Film Program, Video and Home Entertainment
Distribution, please complete the Film Producer and Distributor Application
If coverage is requested for Network Security, please complete the Cyber Security Liability Application
Whenever used in this Application the term Applicant shall mean the named entity, any subsidiary, any
independent contractor while acting on your behalf, but solely as respects media activities and any individual
insured.
SUBMISSION REQUIREMENTS
• Company brochure, marketing or advertising materials
• List of current book titles, periodicals, publications, schedule of programming, broadcasting stations, etc., to
be insured
• Copy of standard contracts used with third parties
• If an Author, current copy of manuscript and any vetting letter from counsel
• Copies of publications or periodicals to be insured, unless available online
• Resumes of principals, if in business less than three (3) years
• Most recent audited financial statement, annual report, or 10K. Non-profit organizations may provide
operating budget.
ACCOUNT INFORMATION
Applicant’s Name:
Applicant’s principal location:
Address:
City: State: Zip:
Telephone: E-mail address:
Website: www. Date established:
SECTION I – GENERAL INFORMATION
1. Idenitfy all media activities for which the Applicant is seeking coverage:
Author Book Publisher Broadcaster – Cable, Radio or Television Stations
Newspaper Publisher Cable TV System Operator Magazine/Newsletter/Periodical Publisher
Public Appearance Online Content Publisher Other:
2. Is the Applicant controlled, owned, affiliated or associated with any other corporation or
company? Yes
No
If yes, please advise:
3. Please list the name(s) and address(es) of any branch offices, joint ventures, affiliates, subsidiaries or other
related entities. Include a brief description of their operations and indicate if coverage is requested:
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Application – Media Liability
Page 2 of 10
4. During the past five (5) years, has the name of the Applicant been changed or has(have)
any other media business(es) been acquired, merged into, or consolidated with the
Applicant?
Yes
No
If yes, provide a complete explanation detailing any liabilities assumed.
5. Geographic area(s) of media operations: Local State Multi-State
National International
6. Does the Applicant belong to any professional societies / associations? Yes No
If yes, provide the designation/affiliation:
7. Dates of the Applicant’s current fiscal period: From: To:
PAST FISCAL
YEAR
CURRENT
FISCAL YEAR
ESTIMATE
NEXT YEAR
Total Gross Annual Revenue: $ $ $
Revenue from Media Operations for which coverage is requested: $ $ $
Revenue from Professional Services performed for others: $ $ $
SECTION II – MEDIA OPERATIONS
MARK ALL SECTIONS FOR WHICH COVERAGE IS REQUESTED
AUTHOR – Book, Play or Article (“Work”)
1. Title of work to be insured:
2. Description of work:
3. a. Scheduled publication date: b. Publisher:
c. Advance: d. Anticipated Revenues:
4. Number of copies, including any reprints, to be distributed (hardback and paperback) during proposed policy
period:
5. Type of work:
Fiction How-To Social/Political/Religious
Autobiography Children’s Financial
Biography Historical Unauthorized biography or “tell-all”
Investigative reporting Poetry Other:
6. Has the work been publicized in a publisher’s catalog or have galley copies been
distributed in advance of the scheduled publication date?
Yes
No
If yes, is Prior Acts coverage needed?
Yes No
7. Has the Applicant’s work been reviewed by counsel? Yes No
If yes, please identify counsel:
8. Has the Applicant’s work been fact-checked by the publisher? Yes No
BOOK PUBLISHER
1. Identify types of books published and assign a percentage to all relevant categories:
Autobiography % Historical %
Biography (authorized) % How-to %
Biography (unauthorized) % Investigative Reporting %
Children’s % Poetry %
Classics % Scholarly/Professional %
Cooking % Social/Political/Religious %
Fiction % Text Books %
Finance % Young Adult %
Other (identify): %
2. For current fiscal year, identify number of original titles: reprints:
3. Does publishing staff edit and fact-check content? Yes No
4. Does publishing staff clear rights for third party content in reprints and subsequent
editions?
Yes
No
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Application – Media Liability
Page 3 of 10
5. Is coverage needed for authors? Yes No
If yes, please explain:
BROADCASTING
1. Radio Stations – attach separate sheet if necessary
Call Letters
(AM or FM)/Location
Years in
Operation
Programming
format
Simulcast %
Revenues
Language
(if not English)
% $
% $
% $
% $
2. Does the Applicant employ any “Shock Jocks” or broadcast other potentially controversial
programming, including talk or contests?
Yes
No
If yes, please describe programming and how exposure is minimized and/or reduced:
3. Are delay devices utilized to minimize exposure arising from offending commentary: Yes No
4. Television and Cable Stations – attach separate sheet if necessary:
Call Letters/
Location
Years in
Operation
Programming
Format
Revenues
Network
Affiliation
Original
Programming %
Language
(if not English)
$
$
$
$
CABLE TV OPERATOR
1. Cable Systems – Attach separate sheet, if necessary
Name
Location
Years in
Operation
Revenues
Original
Programming %
# Access Channels
$
$
$
$
2. If the Applicant creates original programming, please describe the content and the number of hours
broadcast per week?
3. Are channels leased to third parties? Yes No
If yes, are the lessees required to indemnify the Applicant for claims arising from
content?
Yes
No
4. Does the Applicant operate any access channels? Yes No
If yes, does the Applicant have a usage agreement with the public access
broadcaster?
Yes
No
5. Is the public access broadcaster reqired to indemnify the Applicant? Yes No
If yes, is the broadcaster required to carry E&O insurance for claims arising from its
content?
Yes
No
MAGAZINE PUBLISHER
1. Periodicals – Attach separate sheet if necessary:
Name
Location (City & State)
Years in
Operation
Revenues
Circulation
Area
Type of
Content
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Application – Media Liability
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2. Is any of the periodical content controversial or involve any investigative reporting? Yes No
If yes, please explain:
3. Assign a percentage to the source of periodical content produced by the following:
Freelancers: % Staff: % News Service: %
NEWSPAPER PUBLISHER
1. Publications – Attach separate sheet, if necessary.
Name
Location (City & State)
Years in
Operation
Circulation &
Frequency
Revenue
$
$
$
$
2. Circulation area(s)
Rural Metro State Regional National International
ONLINE CONTENT PROVIDER
1. Identify all websites for which coverage is requested:
SPECIAL APPEARANCE
(Public Speaking, Contributing Editor/Author/Writer, Actor, Product Spokesperson)
Attach a separate sheet if necessary.
1. Describe public appearance(s) for which coverage is requested:
2. Number of public appearances on an annual basis:
3. If product spokesperson, please identify client(s), product(s), and attach contract(s):
SECTION III – RISK MANAGEMENT PROCEDURES
USE OF LEGAL COUNSEL
1. Does the Applicant retain law firm(s) with expertise in media law and/or intellectual
property to assist with clearance, content review, and other issues?
Yes
No
If yes, identify firm(s):
2. Does the Applicant utilize in-house media counsel? Yes No
NEWSGATHERING
1. Do employees or freelancers engage in investigative reporting? Yes No
2. Are hidden cameras, microphones, surveillance or other surreptitious methods utilized? Yes No
If yes, describe how risk is minimized:
3. Does the Applicant rely on confidential sources? Yes No
If yes, describe editorial procedures for dealing with confidential sources or information:
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Application – Media Liability
Page 5 of 10
LICENSING AND USE OF THIRD PARTY CONTENT
1. Does the Applicant utilize content created and/or owned by third parties? Yes No
If yes, how is third party content acquired?
2. Do the Applicant’s media operations include the use or playing of unoriginal music? Yes No
If yes, have all rights been cleared:
Mechanical Rights? Yes No
Master Rights? Yes No
Synchronization Rights? Yes No
Blanket music performance licenses through music licensing societies, such as ASCAP? Yes No
If no, will all rights be cleared?
Yes No
3. Does the Applicant’s content include the use of unoriginal photographs, film clips,
graphics, animation, etc.? Yes
No
If yes, are relevant licenses procured?
Yes No
If no, please explain:
4. If famous people, places, and things appear in photographs or stock footage, are rights
cleared with respect to the use of those images? Yes
No
5. Does the Applicant have a procedure for dealing with unsolicited idea submissions of third
parties? Yes
No
6. Does the Applicant rely on “fair use” with respect to unoriginal content? Yes No
If yes, explain:
7. Are independent contractors used to create content? Yes No
If yes, are contracts utilized with independent contractors?
Yes No
If yes, are independent contracts required to maintain errors and omissions
insurance?
Yes
No
CREATION OF CONTENT
1. Does the Applicant commission or use any original music? Yes No
If yes, how is risk minimized:
2. If third parties are commissioned for video or photography, are all licenses procured,
including model releases? Yes
No
OTHER CONTENT ISSUES AND RISK MITIGATION
1. Are staff members with responsibility for content trained with respect to defamation,
invasion of privacy, intellectual property and other exposures? Yes
No
2. Describe procedure for handling retraction and clarification requests:
3. Are disclaimers utilized with respect to any advice that may impact a reader’s health or
financial well-being? Yes
No
4. Is the name, likeness, or portrayal of any living person used in any production or literary
work? Yes
No
If yes, are all clearances obtained?
Yes No
If no, please explain:
5. Is the name, likeness, or portrayal of any deceased person used in any production or
literary work? Yes
No
If yes, have clearances been obtained from heirs or other owners of such rights?
Yes No
If no, please explain:
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Application – Media Liability
Page 6 of 10
WEBSITE AND SOCIAL MEDIA ISSUES
1. Do all websites utilize Terms of Use and Privacy Agreements? Yes No
2. Are licenses procured for any unoriginal streaming content, including music? Yes No
3. Is any user-generated content uploaded to your website(s)? Yes No
If yes, please answer the following:
a. Does the Applicant review content? Yes No
b. Is the Applicant in compliance with Section 230 of the Communications Decency Act
with respect to the handling of third party offending content? Yes
No
c. Is the Applicant in compliance with the Digital Millennium Copyright Act with respect
to notice procedures and the removal of infringing content? Yes
No
d. Is the Applicant able to remove offending or infringing content in a timely manner? Yes No
e. Are procedures in place for dealing with users who repeatedly post offending or
infringing content? Yes
No
4. Does the Applicant utilize social media, such as Twitter, Facebook, or Linked-in? Yes No
If yes, please explain:
a. Who posts content on behalf of the Applicant:
b. Are posts edited or otherwise reviewed prior to posting? Yes No
c. Does the Applicant have written social networking guidelines for employees? Yes No
d. Are employees encouraged to utilize their own social media accounts in the course
and scope of their employment? Yes
No
If yes, please explain:
ANCILLARY PROFESSIONAL SERVICES PERFORMED FOR THIRD PARTIES
1. Does the Applicant provide any professional services related to media operations for a fee,
i.e. advertising or printing services, etc.? Yes
No
If yes, please describe services:
2. Describe how the Applicant minimizes/reduces exposure relating to professional services:
MERCHANDISING
1. Does the Applicant engage in any merchandising activities with respect to media content? Yes No
If yes, please describe:
2. Have all licenses, including trademarks, been cleared with respect to the merchandise? Yes No
3. What annual revenues are anticipated from merchandising activities: $
SECTION IV – INSURANCE HISTORY AND CLAIMS EXPERIENCE
1. Has any policy or application for similar insurance on your behalf or on behalf of any
predecessor(s) in business ever been declined, canceled, or renewal refused? Yes
No
If yes, provide details:
2. Does the Applicant currently carry Commercial General Liability insurance? Yes No
3. Does the Applicant currently carry Network Security coverage? Yes No
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Application – Media Liability
Page 7 of 10
4. Please provide the following information on your Media Liability (E&O) insurance for the past three (3) years:
Name of Insurer: Limits of Liability:$ Deductible:$
Premium: $ Policy period: Occurrence Claims Made
Name of Insurer: Limits of Liability:$ Deductible:$
Premium: Policy period: Occurrence Claims Made
Name of Insurer: Limits of Liability:$ Deductible:$
Premium: Policy period: Occurrence Claims Made
5. Retroactive Date, if one, on current policy:
6. If the Applicant is seeking Subpoena Defense Coverage, please identify how many subpoenas relating to
media operations have been served on the Applicant or any employee in the past three (3) years:
Please explain and provide details:
7. Have any claims or suits been made against the Applicant or the Applicant’s subsidiaries,
predecessor in business, principals or employees in the past five years? Yes
No
If yes, complete a Claim Supplement form for each incident.
8. Is the Applicant aware of any act, error, omission or any other circumstance that is or could
be a basis for a claim under the proposed insurance, including professional services, if so
endorsed?
Yes
No
If yes, complete a Claim Supplement form for each incident.
With regard to questions 6, 7, and 8, it is understood and agreed that if any such claim, act, error, omission,
dispute or circumstance exists, then such claim and/or claims arising from such act, error, omission,
dispute or circumstance is excluded from any coverage that may be provided under this proposed
insurance, and further, failure to disclose such claim, act, error, omission, dispute or circumstance may
result in the proposed insurance being void and/or subject to rescission.
SECTION V – COVERAGE REQUESTED
1. Have any third parties requested coverage as “Additional Insureds” for exposures arising
from your content?
Yes
No
If yes, please advise:
2. Media Liability Coverage requested: Claims Made Policy Retroactive Date:
Occurrence Policy Prior Acts Date:
LIMITS OF LIABILITY
$250,000 $1,000,000 $4,000,000 $7,000,000 $10,000,000
$300,000 $2,000,000 $5,000,000 $8,000,000
$500,000 $3,000,000 $6,000,000 $9,000,000
DEDUCTIBLE: $
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Application – Media Liability
Page 8 of 10
FRAUD NOTICE STATEMENTS
NOTICE TO APPLICANTS: “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 MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL
PENALTIES.”
RESIDENTS OF ALASKA APPLICANTS: “A PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE AN
INSURANCE COMPANY FILES A CLAIM CONTAINING FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY BE PROSECUTED
UNDER STATE LAW.”
RESIDENTS OF ARKANSAS 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.”
RESIDENTS OF ARIZONA APPLICANTS: "FOR YOUR PROTECTION ARIZONA LAW REQUIRES THE FOLLOWING STATEMENT TO
APPEAR ON THIS FORM. ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS
IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES."
RESIDENTS OF COLORADO APPLICANTS: “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.”
RESIDENTS OF DISTRICT OF COLUMBIA APPLICANTS: “WARNING: 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.”
RESIDENTS OF FLORIDA RESIDENTS APPLICANTS: “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 OF THE THIRD DEGREE.”
RESIDENTS OF KANSAS APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE
COMPANY OR OTHER PERSON 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 STATEMENT AS
PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY, OR A CLAIM
FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY 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, COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A
CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.”
RESIDENTS OF KENTUCKY APPLICANTS: “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.”
RESIDENTS OF 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 SUBJECT TO FINES AND CONFINEMENT IN PRISON.”
RESIDENTS OF 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.”
RESIDENTS OF MARYLAND APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WILLFULLY PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY AND WILLFULLY PRESENTS FALSE
INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT
IN PRISON.”
RESIDENTS OF MINNESOTA APPLICANTS: “ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS
FACILITATING A FRAUD AGAINST ANY INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR
DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.”
RESIDENTS OF NEW JERSEY APPLICANTS: “ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN
APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.”
RESIDENTS OF NEW MEXICO 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 CIVIL FINES AND CRIMINAL PENALTIES.”
RESIDENTS OF NEW YORK APPLICANTS: “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 A CIVIL PENALTY NOT
TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.”
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Page 9 of 10
RESIDENTS OF OHIO APPLICANTS: “ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING
A FRAUD AGAINST ANY INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT
IS GUILTY OF INSURANCE FRAUD.”
RESIDENTS OF 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 INFORMATION IS GUILTY OF A FELONY.”
RESIDENTS OF OREGON APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD OR SOLICIT ANOTHER
TO DEFRAUD AN INSURER: (1) BY SUBMITTING AN APPLICATION, OR (2) BY FILING A CLAIM CONTAINING A FALSE STATEMENT AS
TO ANY MATERIAL FACT, MAY BE VIOLATING STATE LAW.”
RESIDENTS OF PENNSYLVANIA APPLICANTS: “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.”
RESIDENTS OF TENNESSEE 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 INCLUDE
IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.”
RESIDENTS OF TEXAS APPLICANTS: IF A LIFE, HEALTH AND ACCIDENT INSURER PROVIDES A CLAIM FORM FOR A PERSON TO
USE TO MAKE A CLAIM, THAT FORM MUST CONTAIN THE FOLLOWING STATEMENT OR A SUBSTANTIALLY SIMILAR STATEMENT:
"ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A
CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON."
RESIDENTS OF VERMONT APPLICANTS: “ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICTION
FOR INSURANCE MAY BE GUILTY OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW.”
RESIDENTS OF VIRGINIA 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 AND DENIAL OF INSURANCE BENEFITS.”
RESIDENTS OF WASHINGTON APPLICANTS: “IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSES OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE
IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS.”
RESIDENTS OF WEST VIRGINIA 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."
Name (Please Print/Type) Title
(MUST BE SIGNED BY THE PRINCIPAL, PARTNER OR
OFFICER
)
____________________________________________________
Signature Date
The above signed warrants that he/she is authorized and has the power to complete and execute this Application, including the
Warranty Statement on behalf of the Applicant and their respective Directors, Officers or other insured persons.
Produced By: (Section to be completed by Producer/Broker)
Producer Agency
Producer License Number Agency Taxpayer ID or SS Number
Address (Street, City, State, Zip)
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Application – Media Liability
Page 10 of 10
ADDITIONAL INFORMATION
This page may be used to provide additional information to any question on this application. Please
identify the question number to which you are referring.
__________________________________________
Signature Date
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MEDIA LIABILITY COVER PRO APPLICATION (Philadelphia Insurance Companies)

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