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Named I PLEASE READ EACH QUESTION CAREFULLY AND (Risk Placement Services, Inc.)

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PLEASE READ EACH QUESTION CAREFULLY AND PROVIDE COMPLETE, TRUTHFUL AND ACCURATE RESPONSES. THE INFORMATION
REQUESTED IN THIS APPLICATION IS IMPORTANT TO THE UNDERWRITING PROCESS. ANY MATERIAL MISREPRESENTATION MAY AFFECT
THE INSURANCE POLICY ISSUED BASED ON THIS APPLICATION.
Named I
nsured as it is to appear on the policy:
DBA:
FEIN/SS:
Corporation
❏
LLC
❏
Partnership
❏
LLP
❏
Individual
❏
Other
❏
Mailing Address:
Inspection Contact Name Phone Number:
Website Address: E-Mail Address
Business Address:
Description of Operations:
Do you conduct any Operations, Businesses or Activities not to be covered under this application of insurance?
Yes
❏
No
❏
If “yes”, please describe:
Expiration Date: Operating Season:
Length of time In Business: Total Management Experience in this type of Operation:
*** If a new Venture or Operation, please attach a Resume or a Summary or Qualifications ***
Limits of Liability Required: Per Occurrence: Aggregate:
Deductible per Claim: $500
❏
$1,000
❏
$2,500
❏
$5,000
❏
Additional Insured (As they are to appear on the Policy):
Check Here if None: ❏
Name Address Relationship to you
Has Your Insurance Ever Been Cancelled or Non-Renewed? Yes
❏
No
❏
If Yes - Please explain:
Submission requirements for all Operations:
❏
Copies of Brochures.
❏
Copy of the Waiver/Release forms signed by all participants
❏
Copy of your EQUIPMENT RENTAL AGREEMENT (Mandatory to Quote Coverage)
❏
Safety Guidelines and/or Safety Program Manual Provided to Your Staff Members
❏
Three Years of Loss Runs from Prior Carriers or A signed letter from the Named Insured stating “No known claims or Incidents”.
(1)
Producing Agent Information
Name of Agent
Address
Telephone Number
PRIOR CARRIER INFORMATION
NAME OF COMPANY
POLICY DATES
PREMIUM
LOSSES
REVENUE BREAKDOWN FOR ALL ACTIVITIES
TOTAL GROSS REVENUES FOR ALL ACTIVITIES: $ ________________________
NON-GUIDED RECREATIONAL EQUIPMENT RENTALS Equipment Age GROSS REVENUES
No
Exposure
BEACH RENTALS: UMBRELLAS, STROLLERS, CHAIRS
BICYCLES
CANOES / KAYAKS / PADDLEBOATS
CROSS COUNTRY SKIS
DOWNHILL SKIS
FISHING BOATS < 50 HP
PONTOON BOATS
RAFTS
SKATES /ROLLER BLADES / SKATEBOARDS
SNOWBOARDS
SURF BOARDS / STAND UP PADDLE BOARDS/WAKEBOARDS
TUBES
WINDSURFERS
REPAIRS
OTHER:
OTHER:
OTHER:
INCIDENTAL OPERATIONS
GROSS REVENUES
CABINS /CAMPING / LODGING / RV
CONCESSIONS
RETAIL SALES OF MERCHANDISE
RESTAURANT
OTHER:
OTHER:
OTHER:
(2)
GENERAL OPERATIONS INFORMATION
1. Are all guests, clients, students required to Sign a Release of Liability Prior to renting any equipment? __ Yes __ No
2. Do you require guests, clients, students to complete a health & physical fitness form or declare their fitness? __ Yes __ No
3. Do you hire sub-contractors, Independent Contractors or concessionaires? __ Yes __ No
If “yes” – Please describe ______________________________________________________________
If “yes”– Do you obtain Proof of Insurance with AI status from them? __ Yes __ No
4. Do you report ALL INCIDENTS regardless of severity to your insurance company immediately? __ Yes __ No
5. Do you deliver equipment to renters? __ Yes __ No
6. Do you provide any type of transportation to or from a location? __ Yes __ No
If “yes”, please describe & If a river provide the Class of the River ______________________________
7. Do you inspect each piece of equipment after each rental and make repairs immediately? __ Yes __ No
8. Do you keep a log of all inspections and repairs including the date and type of repair? __ Yes __ No
9. Do you maintain and retire the equipment per manufacturer’s recommendations? __ Yes __ No
10. Do you provide any instruction or classes? __ Yes __ No
If “yes” Please describe: ________________________________________________________________
11. Do you check weather forecast and conditions prior to the commencement of any activities or trips to ensure client safety? __ Yes __ No
WATERCRAFT & TUBE RENTALS NO EXPOSURE
1. Do you provide U.S. Coastguard approved PDFs for each person that will be aboard a watercraft or renting a tube? __ Yes __ No
2. If your rental location is river specific – what class River are you on? ____________________________
3. Do you rent Tubes or Watercraft on a Dam release river? __ Yes __ No
If “yes”, what class rapid/whitewater does the River become during the Dam Release? _____________
If “yes”, what is your procedure for ensuring that rentals are off the river during a release? _______________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
4. Do you provide a safety speech advising the renters of the hazards of the dam release if during rental hours? __ Yes __ No
5. What is your minimum age for allowing participants on the river in your rentals? _____________
6. Do you verify that the renter of a motorized watercraft has a valid in-force driver’s license prior to renting? __ Yes __ No
# Of
CRAFT
LENGTH, MAKE AND MODEL OF RAFT
ENGINE
HP
# OF
PASS.
CLASS OF RIVERS ( 1 – 5 )
OR NAME OF LAKE OPERATED ON
(3)
SKIING / SNOWBOARDING EQUIPMENT RENTAL NO EXPOSURE
1. Are all employees Trained and Certified by the manufacturer to outfit patrons and adjust bindings as suited? __ Yes __ No
If “yes” please list the Manufacturers: ______________________________________________________
2. What is the minimum age for renting equipment: _____________________________________________
BICYCLE / SKATEBOARD / IN-LINE RENTALS / SKATES NO EXPOSURE
1. Do you provide fitted safety helmets for all rentals / riders? __ Yes __ No
CAMPING / CABINS / LODGING / SWIMMING NO EXPOSURE
1. Total Number of Camping/ Tent Sites Available: _________________
2. Total Number of RV Spaces Available: ____________ Describe Utility Hookups _______________________________________________
3. Total Number of Cabins Available: ________________ If Lodge – Number of Units: ___________________ Date Built: _____________
4. Do All Cabins / Lodge Units Have Smoke Alarms? __ Yes __ No
5. Are Individuals Allowed to Cook within the cabins? __ Yes __ No
6. Is there a Swimming Pool or Swimming Area Available for Use? __ Yes __ No
If “yes” is there a Diving Board or Slide? __ Yes __ No
If “yes” are all Local and State Rules & Regulations regarding Signage Complied with? __ Yes __ No
Are there Lifeguards monitoring the swimmers? __ Yes __ No
7. Are all Swimming Pools & Spas compliant with the Virginia Graeme Baker Pool and Spa Safety Act? __ Yes __ No
8. Are all Local and State Rules & Regulations regarding pool/spa chemical monitoring and logging complied with? __ Yes __ No
9. Have you even received a citation or warning with respects to the pool/spa from State or Local Authorities? __ Yes __ No
If “yes”, please describe the citation and how the citation was remedied: ______________________________________________________
________________________________________________________________________________________________________________
CONCESSIONS / RESTAURANT NO EXPOSURE
1. Are Grills and Cooking Surfaces Protected by a Fire Suppression System per local / State codes? __Yes __ No
If “no”, please describe the Fire Protection present: ___________________________________
2. Are you in compliance with all State and Local Health Codes with regards to food preparation and storage? __ Yes __ No
If “no”, please describe why: ______________________________________________________
3. Have you ever been cited for a health violation? __ Yes __ No
If “yes” – describe citation and how remedied: ________________________________________
(4)
RETAIL SALES OF MERCHANDISE AND SOUVENIRS NO EXPOSURE
PLEASE IN DICATE IF YOU SELL ANY OF THE FOLLOWING MERCHANDISE IN YOUR STORE:
1. Do you repair or sell used equipment? __ Yes __ No
If “yes” – do you have a warranty or guarantee or return policy that you provide? __ Yes __ No
If “yes” – please provide a copy or describe: _____________________________________________________________________________
_________________________________________________________________________________________________________________
2. Provide a general description of the types of items you have for sale in your store.
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
3. Do you sell hunting or fishing permits? __ Yes __ No
(5)
❏
AMMUNITION
❏
GENERAL STORE
❏
RELOADS
❏
FIREARMS
❏
ARROWS
❏
KNIVES
❏
BLACK POWDER
❏
SCUBA DIVING EQUIPMENT
❏
BOWS-MANUAL
❏
WATERCRAFT
❏
BOWS-MECHANIZED
❏
T-SHIRTS & SOUVENIRS
❏
OTHER: __________________
❏
OTHER: __________________
NON-GUIDED EQUIPMENT RENTALS MINIMUM ELIGIBILITY REQUIREMENTS – PLEASE READ CAREFULLY
BY AFFIXING MY INITIALS I HEREBY AGREE TO ADHERE TO THE FOLLOWING MANDATORY INSURABILITY REQUIREMENTS AS A CONDITION FOR
OBTAINING INSURANCE COVERAGE
*** PLEASE READ EACH AND EVERY REQUIREMENT CAREFULLY ***
No. Initials Requirements
1.
A safety orientation and/or briefing shall be conducted for each participant that includes a description of the activity itself, the
inherent dangers of the activity, safety precautions while underway and what to do in the event of an emergency or accident.
2.
A Waiver and release of liability approved by us, recognizing the dangers of the activities will be signed and obtained from all
participants. In addition to the customer’s signature, the form will have a parent’s or legal guardian’s signature if the participant
is under legal age. One waiver per customer is a requirement – roster type waivers are NOT acceptable. Waivers will be kept on
file for a minimum of 3 years
3.
Drugs and alcohol are prohibited. As such, you shall not allow any participant(s) to participate when you know, suspect or
believe that those individuals are or may be under the influence of alcohol or drugs.
4.
All applicable State, Federal and Equipment Manufacturer’s safety standards for the operations (including passenger capacity)
are to be followed at all times during activities. Each participant will wear applicable safety equipment
5.
You shall inspect all equipment / units / watercraft daily, and prior to the commencement of any activities. You shall make
necessary repairs to ensure your patron’s safety. You shall maintain and keep a written log of these inspections and repairs.
6.
Records of each rental with times and dates must be maintained along with the waivers and including, incident / injury reports
for a minimum of 3 years
7.
All incidents regardless of severity will be reported to the company immediately.
8.
You shall have a procedure in place for lost or late returning patrons.
9.
You shall, to the best of your ability, determine the client’s physical ability to participate in the activity and ensure that they are
properly attired for both the activity and the weather conditions.
10.
Employees must be properly trained and experienced on all activities to enforce all eligibility and safety requirements.
11.
The minimum age for renters of rental equipment is 18 years. A parent or guardian must sign the waiver and/or release for any
person Under 18 years of age that is using the equipment.
12.
Customers shall be fitted and provided with an approved United States Coastguard personal flotation device, which must be
worn by each participant at all times while on/in any watercraft, water vehicle or tube
13.
Customers will be provided with, and must wear an industry approved helmet for all Class IV and Class V River Raft Rentals.
14.
You shall ensure that all motorized watercraft renters have a valid and in-force driver’s license before allowing operation of the
watercraft.
15.
Bicycle / Skateboard / Skates: Customers will be fitted for and provided an industry approved helmet / headgear.
IN THE EVENT YOU ARE UNABLE TO INITIAL ANY SECTION ABOVE, PLEASE PROVIDE AN EXPLANATION OF THE ALTERNATIVE PROCEDURE THAT YOUR
OPERATION IS UNDERTAKING BELOW. THIS WILL BE SUBMITTED TO THE COMPANY FOR APPROVAL
No. Explanation and Comments:
I understand that R.B. Jones Insurance for the insuring company, shall be permitted but not obligated to inspect a proposed insured's, or an
insured's, property and operations for underwriting purposes at any time. Neither the right to make an underwriting inspection nor the making thereof nor
any report thereon shall constitute an undertaking, on behalf of or for the benefit of any insured, or other, to determine or warrant that such property or
operations are safe or healthful, or in compliance with any standards, rules or regulations. Underwriting inspections when conducted are for the sole
purpose of determining and/or improving the insurability of certain property and operations and not safety. I also understand that an insured is solely
responsible for the safety of its facilities and operations and shall not rely upon any underwriting inspections to determine the safety of its facilities or
operations and shall not diminish or forego its own safety practices and procedures.
By signing this application below, you are attesting to the accuracy and completeness of the information being
provided in response to the questions set forth above.
_
____________________________________________________ _____________________________________________ _____________
APPLICANT’S SIGNATURE & TITLE PRINTED NAME & TITLE DATE
(6)
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R. B. JONES AND UNDERWRITERS ANTI-FRAUD STATEMENT
THIS ANTI-FRAUD STATEMENT IS AN INTEGRAL PART OF YOUR APPLICATION FOR INSURANCE AND ANY INSURANCE POLICY
THAT MAY BE ISSUED BASED ON THE INFORMATION PROVIDED. PLEASE READ THIS CAREFULLY
A person commits a fraudulent insurance act if that person knowingly and with intent to defraud or deceive any insurance
company or other person either (a) files an application for insurance or statement of claim containing any materially false
information, or (b) conceals information concerning any material fact in order to obtain an insurance policy or benefit under an
insurance policy. A fraudulent insurance act is a crime. (In Oregon, a fraudulent insurance act may be a crime.) R.B. Jones and the
Underwriters shall pursue prosecution of any fraudulent insurance act to the fullest extent of the law.
For residents of Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement or claim or an
application containing any false, incomplete or misleading information is guilty of a felony of the third degree.
For residents of New Jersey, Arkansas, and New Mexico: Any person who knowingly files a statement of claim containing any false or
misleading information is subject to criminal and civil penalties. Any person who includes any false or misleading information on an
application for an insurance policy is subject to criminal and civil penalties.
FOR RESIDENTS OF CALIFORNIA: FOR YOUR PROTECTION, CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON
THIS FORM: 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.
For residents of 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 its agent who knowingly provides false, incomplete, or misleading information to a policyholder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to an insurance settlement or award
shall be reported to the Colorado Division of Insurance.
For residents of Louisiana: 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.
For residents of 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 also be subject to a civil
penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
For residents of 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 a person to criminal and
civil penalties.
For residents of Puerto Rico: Any person who knowingly and with the intent to defraud, presents false Information in an insurance request
form, or who presents, helps or has presented a fraudulent claim for the payment of a loss or other benefit, or presents more than one claim
for the same damage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine no less than five
thousand (5,000) dollars nor more than ten thousand (10,000) dollars, or imprisonment for a fixed term of three (3) years, or both penalties.
If aggravated circumstances prevail, the fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating
circumstances prevail, it may be reduced to a minimum of two (2) years.
For residents of Virginia: 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.
For residents of Washington: It is a crime to knowingly provide false, incomplete, or misleading information to insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
The undersigned acknowledges having read this Anti-Fraud Statement.
Applicant _________________ Date __________________
(7)
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Named I PLEASE READ EACH QUESTION CAREFULLY AND (Risk Placement Services, Inc.)

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Completed 30 July 2020

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