Fillable OUTFITTER & GUIDE APPLICATION (Philadelphia Insurance Companies)

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OUTFITTER & GUIDE APPLICATION (Philadelphia Insurance Companies)

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OUTFITTER & GUIDE APPLICATION
SUBMISSION REQUIREMENTS
• All brochures describing any and all services; or website address.
• The liability waiver/hold harmless agreement you require your 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
1. Do you operate any other business 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 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:
ADDRESS:
TELEPHONE: FAX:
E-MAIL:
THIS IS AN APPLICATION FOR INSURANCE. THIS IS NOT A BINDER OF INSURANCE.
State: Zip:
County: State: Zip:
Fax Number:
Risk Management’s Phone:
Named Insured:
Principal Contact:
Mailing Street Address:
Mailing City:
Location Street Address:
Location City:
Phone Number:
Website: www.
Risk Management Contact:
Risk Management Email:
Business Type: Corporation Partnership Individual LLC Other:
Effective Date:
Limit of Liability requested: $ 300,000 Occurrence
$ 500,000 Occurrence
$1,000,000 Occurrence
Outfitters and Guide Application - Florida
Page 1 of 8
© 2018 Philadelphia Consolidated Holding Corp.
12/2018
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ACTIVITY INFORMATION
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 $
Hunting $
Shooting Range – Rifle or Pistol $
Hiking / Backpacking $
Horseback Riding $
Hay, Sleigh or Wagon Rides $
Lodging / Cabin Rentals $
Retail Store $
Bike Rentals $
Mountain Bike Riding $
Road Cycling $
Boating $
Jet Skis or Wave Runners $
River Tubing $
Sea Kayak Tours /Rentals $
Waterskiing $
Whitewater Rafting $
SCUBA Diving $
Cross Country Skiing $
Dog Sled Tours $
Downhill Skiing $
Snowshoeing $
ATV-guided $
ATV-unguided $
Snowmobiles-guided $
Snowmobiles-unguided $
Climbing Wall $
Rock Climbing $
Paintball $
Youth Camps or Programs $
Other, describe: $
OPERATIONS INFORMATION
1. Do you require guests to sign a liability waiver? Yes No
2. Do you require guests to complete a health & physical fitness form? Yes No
3. Do you have a brochure or web page? Yes No
4. How many years have you been in business? Years
5. If you are a new venture, how many years of prior experience? Years
6. Are any operations conducted outside of the United States? Yes No
7. Do you hire guides as sub-contractors? Yes No
If yes, for what activities?
If yes, do you obtain proof of insurance? Yes No
8. Is your business operational year round? Yes No
If no, number of months you are operational? Months
Outfitters and Guide Application - Florida
Page 2 of 8
© 2018 Philadelphia Consolidated Holding Corp.
12/2018
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GUIDE INFORMATION
Name Age Years Experience First Aid Qualifications
LODGING SECTION N/A
Guest Quarters
1. Total number of units for guest rental?
2. Number of RV spaces: Tent sites:
3. Maximum guest capacity is:
4. Do all cabins / units have smoke alarms? Yes No
5. Do you have a swimming pool or swimming area? Yes No
If yes, do you have a diving board? Yes No
6. 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
RETAIL OPERATIONS N/A
1. Do you have retail operations for any of the following?
General Store Ski Equipment Sales Fishing Equipment Sales
Liquor Store Ski Equipment Rental Fishing Equipment Rental
Gun Sales Restaurant
2. What are your total gross sales from retail operations? $
HUNTING SECTION N/A
1. What is the maximum guide to guest ratio? Guides to Guests
2. What is the maximum number of hunters at any one time?
3. Do you operate drop camps? Yes No
4. Is livestock provided with drop camps? Yes No
5. What percentage of your hunting operations are unguided? %
6. What type of game is being hunted?
Elk Deer Exotics Bear Turkey
Waterfowl Upland Birds Hogs Other, describe:
7. Are Tree Stands used? Yes No
If yes, are safety harnesses required? Yes No
8.
Do you use any of the following to transport hunters? If yes, how
many?
ATVs:
Horses:
Snowmobiles:
Boats:
Other Unlicensed Vehicles:
9. If ATVs and/or Snowmobiles are used, are helmets required while riding? Yes No
Outfitters and Guide Application - Florida
Page 3 of 8
© 2018 Philadelphia Consolidated Holding Corp.
12/2018
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BICYCLE SECTION N/A
Tour Information
1. Maximum number of cyclists on a tour?
2. Maximum number of tours operating on the same day?
3. Number of guides on a tour?
4. Are helmets required? Yes No
5. What is the percentage of tours operated: Off Road % vs. On Roadways %
6. Do you pre-screen guests to determine ability prior to riding? Yes No
7. Do guides carry any communication device with them?
(2-way radio, cell phone, etc.) Yes No
If yes, what type?
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
Yes No
Yes No
Yes No
WATERCRAFT GENERAL INFORMATION
1. What type of operation do you 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
CANOE, KAYAK, AND / OR RIVER TUBING INFORMATION N/A
Boat Type Maximum Number Used Average Number Used
Canoes
Kayaks
Tubes
1. What percent of your 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 you will allow on a horse? Years Old
5. Do you offer the use of helmets? Yes No
6. Do you ever allow double riding? Yes No
7. What percentage of your guests ride: Western Saddle? % vs. English Saddle? %
8. What percentage of your horse operations are: Unguided? % vs. Guided? %
9. What is the maximum guide to guest ratio? Guides to Guests
10. Do you operate pony rides? Yes No
If yes: Trail Ride Riding Ring Hand Led Other(describe):
Outfitters and Guide Application - Florida
Page 4 of 8
© 2018 Philadelphia Consolidated Holding Corp.
12/2018
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GUEST & SAFETY INFORMATION
1. Do you require guests to complete a physical fitness information form prior to
riding? Yes No
2. Do you pre-screen guest riders and determine ability prior to riding? Yes No
3. Do guides carry any communication device with them
(2-way radio, cell phone, etc.?) Yes No
4. Do you conduct a pre-ride safety briefing with guests? Yes No
5. Do you provide a written safety manual of procedures to all staff members? Yes No
If yes, provide a copy.
6. List reasons why you would decline a person from riding (health, age, weight,
alcohol, general, pregnancy):
7. Do you board horses for a fee? Yes No
If yes, how many?
8. Do you teach or allow your guest to participate in:
Dressage Cattle Drives Inoculations Barrel Racing
Horse Jumping Team Penning Sleigh Rides Branding Cattle
Horse Racing Roping Cattle Hay Rides Handling Livestock
Buckboard / Buggy Rides
9. Are guests allowed to handle, rope or brand livestock? Yes No
10. If you conduct cattle drives, what is the number of:
Wranglers to Riders Maximum Duration: Maximum Distance:
11. If your ranch conducts a Rodeo/Gymkana, describe what activities your guests may participate in:
LOSS HISTORY
Date Description of Incident Amount Paid/Reserved
$
$
$
1. Do you have knowledge of any incident which may lead to a claim? Yes No
If yes, please describe:
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Outfitters and Guide Application - Florida
Page 5 of 8
© 2018 Philadelphia Consolidated Holding Corp.
12/2018
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FRAUD NOTICE STATEMENTS
APPLICABLE IN FLORIDA: 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).
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
.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR
EXECUTIVE DIRECTOR)
____________________________________________________
SIGNATURE DATE
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)
Outfitters and Guide Application - Florida
Page 6 of 8
© 2018 Philadelphia Consolidated Holding Corp.
12/2018
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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 th
e Applicant alleging i
nvasion 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
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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 KNOW
INGLY 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.
NAME (PLEASE PRI
NT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
____________________________________________________
SIGNATURE DATE
SECTION TO BE C
OMPLETED BY THE PRODUCER/BRO
KER/AGENT
PRODUCER AGENCY
(I
f 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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OUTFITTER & GUIDE APPLICATION (Philadelphia Insurance Companies)

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