Fillable OUTFITTER & GUIDE APPLICATION-FLORIDA (Philadelphia Insurance Companies)

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OUTFITTER & GUIDE APPLICATION-FLORIDA (Philadelphia Insurance Companies)

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Gillingham & Associates ▪ A Member of Philadelphia Insurance Companies
8501 Turnpike Drive, Suite 200 ▪ Westminster, CO 80031
Toll Free: 800-849-9288 ▪ In Colorado: 303-428-5400 ▪ Fax: 303-428-5900
www.outdoorinsurance.com
▪ www.phly.com
Page 1 of 6
OUTFITTER & GUIDE APPLICATION-FLORIDA
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
Named Insured:
Principal Contact:
Mailing Street Address:
Mailing City: State: Zip:
Location Street Adress:
Location City: County: State: Zip:
Phone Number: Fax Number:
Effective Date: Website: www.
Business Type: Corporation Partnership Individual LLC Other:
Limit of Liability requested: $ 300,000 Occurrence
$ 500,000 Occurrence
$1,000,000 Occurrence
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.
Clear Application
Print Application
Gillingham & Associates ▪ A Member of Philadelphia Insurance Companies
8501 Turnpike Drive, Suite 200 ▪ Westminster, CO 80031
Toll Free: 800-849-9288 ▪ In Colorado: 303-428-5400 ▪ Fax: 303-428-5900
www.outdoorinsurance.com
▪ www.phly.com
Page 2 of 6
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
Clear Application
Print Application
Gillingham & Associates ▪ A Member of Philadelphia Insurance Companies
8501 Turnpike Drive, Suite 200 ▪ Westminster, CO 80031
Toll Free: 800-849-9288 ▪ In Colorado: 303-428-5400 ▪ Fax: 303-428-5900
www.outdoorinsurance.com
▪ www.phly.com
Page 3 of 6
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
Clear Application
Print Application
Gillingham & Associates ▪ A Member of Philadelphia Insurance Companies
8501 Turnpike Drive, Suite 200 ▪ Westminster, CO 80031
Toll Free: 800-849-9288 ▪ In Colorado: 303-428-5400 ▪ Fax: 303-428-5900
www.outdoorinsurance.com
▪ www.phly.com
Page 4 of 6
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):
Clear Application
Print Application
Gillingham & Associates ▪ A Member of Philadelphia Insurance Companies
8501 Turnpike Drive, Suite 200 ▪ Westminster, CO 80031
Toll Free: 800-849-9288 ▪ In Colorado: 303-428-5400 ▪ Fax: 303-428-5900
www.outdoorinsurance.com
▪ www.phly.com
Page 5 of 6
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:
NOTICE TO APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY
O
R 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.
Fraud Notice
Clear Application
Print Application
Gillingham & Associates ▪ A Member of Philadelphia Insurance Companies
8501 Turnpike Drive, Suite 200 ▪ Westminster, CO 80031
Toll Free: 800-849-9288 ▪ In Colorado: 303-428-5400 ▪ Fax: 303-428-5900
www.outdoorinsurance.com
▪ www.phly.com
Page 6 of 6
NOTICE TO FLORIDA 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.
Insured Signature : _______________________________________ Date:
Name of Authorized Agent or Broker:
License No.
Date:
Signature:
Title:
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Completed 29 July 2020

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