MOTORSPORTS FACILITY APPLICATION
SUBMISSION REQUIREMENTS
Complete ACORD Property, Auto and Umbrella Liability if coverages requested
Diagram of track
Evidence of Participant Accident coverage
Contracts with and certificates of insurance from sub-contractors if any
Complete annual event schedule
Photos
Latest financial statement
Emergency evacuation plan
Currently valued insurance company loss runs for the current policy period plus four prior years
SECTION I - GENERAL INFORMATION
1. Applicant name:
2. Name of facility:
3. Mailing address:
Physical address:
4. Does the Applicant own or lease the facility? Own Lease
5. Contact person: Telephone:
Contact e-m
ail: Web site address: www.
6. Busine
ss type: Corporation Partnership
Governmenta
l entity
Non-Profit Individual Other:
7. Year business was established:
Number of years under present management:
FEIN:
8. List all Named Insureds and their interest:
Note: All First Named Insureds require common / majority ownership of any Named Insured
If not, please explain.
a.
b.
c.
d.
e.
Explanation:
9. Does the Applicant have any inflatable, fabric or air supported structures such as,
but not limited to, bubbles or domes? Yes No
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SECTION II - OPERATIONS
1. Type of facility: Oval Dragstrip Road course Motocross
Karting Dirt track Paved
2. Does the Applicant operate the track under a sanctioning body rules? Yes No
If yes, what sanctioning body:
If no, provide copies of racing rules.
3. Oval Tracks:
a. Track length:
b. Degree of banking: Low Average High
c. Events scheduled: Closed wheel
Open wheel Enduros Cycle / ATV
Other:
d. Are reinforced right-front wheels require
d on all cars
(except open wheel)? Yes No
e. Are 4-point roll bars (minimum) required on all cars? Yes No
f. Are all doors securely fastened? Yes No
4. Drag Racing:
a. Strip length:
b. Shut down length:
c. Surface: Sand Mud Grass Water Paved
d. Scheduled events include more than ten (10) of the following vehicles:
Jets Blown alcohol Blown nitro methane
e. Any events involving motorcycles only? Yes No
5. Road Course:
a. Length of course:
b. Can the course be divided into shorter courses? Yes No
c. If yes, what is the length of each course?
6. Go-Karts:
a. Number of tracks:
b. Number of owned go-karts:
c. Minimum age requirement:
d. Are helmets required? Yes No
e. Maximum go-kart speed:
f. Are governors installed to control speed? Yes No
g. Are participants required to wear seat belts? Yes No
If no, explain:
h. Is a remote control device for emergency shut down of go-karts utilized? Yes No
i. Are go-karts equipped with roll bars and bumper guards? Yes No
j. Is proper signage & enforcement of loose clothing and hair restraints in
place?
Yes No
k. Who is the manufacturer of owned go-karts:
l. Are participants permitted to race their own go-karts? Yes No
m. Are go-karts inspected by insured employees to confirm they meet safety
requirements?
Yes No
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7. Concessions and Alcohol:
a. If facility operated, provide receipts: $
b. If sub-contracted, is certificate of insurance with Additional Insured status
provided?
Yes
No
c. Are alcoholic beverages sold / distributed on premises? Yes No
d. If yes, what type:
e. If yes, have servers been trained in a state alcohol awareness program? Yes No
f. License number:
g. Do you allow spectators to bring their own alcohol on premises? Yes No
h. If yes, describe controls in place:
8. Other:
a. Does the Applicant sell any of the following:
Automobile parts: Yes No New Used
Automobile tires: Yes No New Used
b. Does the Applicant or its’ employees provide repair or mechanical services? Yes No
If yes, does the Applicant have garage liability or garagekeepers liability
coverage in place?
Yes
No
SECTION III – SAFETY INFORMATION
1. Barriers:
a. Type of barrier: Concrete Highway Steel Other:
b. Does the barrier / guardrail protect all spectator areas? Yes No
c. Does the barrier / guardrail protect all pit areas? Yes No
d. Does the barrier / guardrail protect all private property? Yes No
e. Are spectators and participants contained behind a position barrier by crowd
control fence?
Yes No
f. Any ancillary spectator areas (parking lots, walkways, etc.) protected with the
same minimum barriers and fencing as the main grandstand area?
Yes No
g. Distance of grandstands from track:
2. Fencing:
a. Height of debris fence:
b. Is the fence cantilevered? Yes No
c. Is the pit / pad dock area completely fenced from spectator area? Yes No
d. Is pit road completely fenced? Yes No
e. Distance of spectator to racing surface:
3. Security:
a. Any employed armed security?
IF YES, COMPLETE SECTION VII
I OF THIS APPLICATION
Yes No
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SECTION IV – EMERGENCY ELEMENTS
1. Medical Service:
a. Is a state-certified ambulance on site? Yes No
b. Are a minimum of two (2) licensed EMT’s provided? Yes No
c. If sub-contracted EMT’s, are certificates of insurance on file? Yes No
d. If employed EMT’s, is the Applicant compliant with state requirements? Yes No
e. Distance to nearest hospital:
f. Ambulance service on call? Yes No
2. Fire Equipment
a. Is fire equipment provided? Yes No
b. Is fire equipment contracted? Yes No
c. Describe on-site fire equipment:
SECTION V – PARTICIPANT EXPOSURES
1. Is a waiver and release form signed by all participants and other persons? Yes No
2. Are approved helmets required? Yes No
3. Are trained / certified race vehicle technician inspectors provided? Yes No
4. Are approved restraint belts required? Yes No
5. Are drivers under the age of sixteen (16) permitted? Yes No
If yes, in what class?
6. What age limit?
SECTION VI – SPECTATOR EXPOSURES
1. Grandstands:
a. Age of grandstands:
b. Seating capacity:
c. Average weekly attendance:
d. Construction: Wood/Metal Metal/Metal Concrete
Other (explain):
Inspected: Weekly Monthly Semi-annual Annual
e. Parking
area composition:
Inspected: Weekly Monthly Semi-annual Annual
f. Is there playground equipment? Yes No
If yes, provide a description:
2. Camping:
a. Is overnight camping permitted during non-race activities? Yes No
b. Annual camping receipts: $
c. Number of spaces:
d. Are hookups provided? Yes No
f. Is security on site during all camping hours? Yes No
3. Open Water:
a. Is there any open water on your immediate property? Yes No
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SECTION VII – ADDITIONAL EXPOSURES
1. Does the Applicant have any of the following?
Monster trucks Skydivers Stunt performers
Jet car burns Coin tosses Kids bike races
Amusement rides Firework displays
Other (describe):
2. Non Racing Events:
Swap meets - # of admissions: Con
certs - # of admissions:
Trade shows - # of admissions: Mall shows - # of admissions:
Driving schools - # of admissions: Other (describe):
3. Will these events be self promoted? Yes No
If no, does the Applicant obtain certificates of insurance with additional insured
status from promoter(s)?
Yes No
4. Additional Insured(s):
Please list all additional insureds and their interest(s):
Name and address Interest
SECTION VIII - SECURITY
(Complete only if security is the responsibility of the Applicant)
1. Who is primarily responsible (via contract) for liability coverage for security personnel?
Insured? Yes No
Municipality? Yes No
Sub-contractor? Yes No
2. Employed or sub-contracted security personnel? Employed Sub-contracted
“Employed” is defined as individuals being paid and supervised directly by the insured. “Contract” is
defined as the existence of a written contract with another entity for security services that have
separate insurance coverage and provide a certificate naming the Insured as Additional Insured with
limits equal to or greater than the Insured.
3. Number and payroll of employed security personnel:
Unarmed: # Payroll: $
Armed (not including off duty police officers): # Payroll: $
Off duty police officers: # Payroll: $
4. Sub-contracted security – cost of sub-contract: $
5. Total maximum hours per day permitted at this and all other places of employment:
Total maximum hours per week:
6. What are the staffing guidelines per number of patrons?
Are the guidelines determined by:
Ordinance? Yes No
Statute? Yes No
Industry standard? Yes No
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Other: (describe)
7. Is there a procedure to immediately report all incidents to the facility manager? Yes No
If yes, describe:
8. Does the supervisor make personal contact with each security person at least
once during each shift? If yes, describe:
Yes No
9. Does the procedure include contacting previous employers over the previous
five (5) years?
Yes No
10.
Does the Applicant contact at least three (3) personal references? If no, describe: Yes No
11.
Is completion of a minimum twenty (20) hours initial training program required
before deployment? Yes No
12. Who conducts the training and what are the trainer’s qualifications:
13. Is a minimum of ten (10) hours on-site training required? Yes No
14. Is a minimum of four (4) hours of annual refresher or continuing education
training planned and conducted for each security employee? Yes No
15. Is each security person given a personal copy of the training / safety manual? Yes No
If yes, has each security person given management a written acknowledgment
of the policies and contents? Yes No
NOTE: PLEASE INCLUDE A COPY OF THE MANUAL AND A SAMPLE OF THE WRITTEN
ACKNOWLEDGEMENT.
ARMED SECURITY EMPLOYEES:
1. Are the security personnel in uniform? Yes No
If yes, describe the uniform:
2. Are the security personnel identified by anything other than a uniform? Yes No
If yes, describe the identification and include an example or photograph.
3. Are psychological screen profiles used? Yes No
If yes, specify type:
4. Are criminal background checks completed? Yes No
If yes, what agency is utilized?
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5. Please indicate any equipment carried or routinely available to security personnel:
Flashlight Type: Size: Construction:
Handcuffs First aid kit (including blo
od borne pathogen kit)
Night
stick Is night stick police regulation or other?
Taser / Phaser Chemicals (Mace, pepper gas)
Other:
Firea
rm
Caliber: .357 .38 .9mm Other:
Make:
Colt S & W Ruger Other:
Cover
Holster Type:
6. Is the ammun
ition:
Standard O
ther (describe):
7.
Are firea
r
m a
nd ammu
nitio
n
approved a
nd inspe
c
ted
by manage
ment or the
security company? Yes No
8.
Describe capabilities of each guard for constant communications with each other, the supervisor,
and management:
9. Are dogs used in the Applicant's security operations? Yes No
If yes, provide the type of dogs, number, and describ
e duties.
SECTION IX – HIRED & NON-OWNED AUTO
1. Does the Applicant have any owned automobile? Yes No
NOTE: If the Applicant has owned autos, the hired car and non-owned auto
coverage should be placed with the automobile carrier. Explain if an exception is
requested.
2. Do employees use their personal autos for your business purposes? Yes No
If yes, how often? Daily Weekly Monthly Other:
3. Do the Applicant obtain Motor Vehicle Reports? Yes No
If yes, how often? Annually Every other year Other:
4. Does the Applicant confirm that all employees who regularly use their cars for
business purposes carry minimum personal auto limits? Yes No
If yes, what minimum limits are required: $
5. Please provide the approximate cost of hire for all hired or leased autos during the
course of the policy period: $
6. Is hired auto physical damage required? Yes No
If yes, what is the maximum value of the hired vehicle you would like to insure? $
NOTE: Physical Damage Deductibles: $100 comprehensive / $1,000 collision provided.
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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
SE
CTION 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)
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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 again
st the 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)
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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 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, 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.
NAM
E (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
____________________________________________________
SIGNATURE DATE
SECT
ION TO BE COMPLETED BY THE P
RODUCER/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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