Fillable Outfitters and Guides Program Supplemental Application (RT Specialty)

Fill Online, Printable, Fillable, Blank Outfitters and Guides Program Supplemental Application (RT Specialty) Form

Use Fill to complete blank online RT SPECIALTY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Outfitters and Guides Program Supplemental Application (RT Specialty)

On average this form takes 33 minutes to complete

The Outfitters and Guides Program Supplemental Application (RT Specialty) form is 4 pages long and contains:

  • 3 signatures
  • 3 check-boxes
  • 117 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your RT Specialty forms online.

BROWSE RT SPECIALTY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675 • Fax (480) 483-6752
www.scottsdaleins.com
Outfitters and Guides Program Supplemental Application
(Complete in addition to ACORD General Liability Application)
Name of Applicant:
Website Address:
E-mail Address: Phone Number:
Location Address:
1. Description of operations:
2. Errors and Omissions (E&O) Coverage (available up to General Liability Limits): Each Claim $
Aggregate $
3. Type of license (if applicable):
4. Applicant’s prior experience:
5. Activities of applicant:
a. Guides Number of Guides Number of Guides
Hunting Cross-country Skiing
Fishing Backpacking
Combination Hunting & Fishing Hiking
b. Pack animals/saddle animals Number of Animals Number of Animals
Pack animals Saddle animals
c. Outfitters
Sale of equipment gross receipts: $ Rental of equipment gross receipts: $
d. Guest lodging
Description of lodging provided:
Total number of beds:
Swimming pool provided? ..................................................................................................................... Yes No
e. Boats/ATVs/Snowmobiles
Number of boats:
Length of boats and horsepower:
Number of applicant owned ATVs: Number of applicant owned Snowmobiles:
Does applicant provide each boat passenger with a U.S. Coast Guard approved personal flotation
device? ..................................................................................................................................................
Yes No
GLS-APP-42s (10-13) Page 1 of 4
Submit Here
6. Is applicant involved with any of the following activities:
a. Aircraft exposures? ............................................................................................................................... Yes No
b. ATV tours? ............................................................................................................................................ Yes No
c. Bicycle tours using public roads? .......................................................................................................... Yes No
d. Canoe/kayak watercraft exposures? ..................................................................................................... Yes No
e. Deep sea fishing? ................................................................................................................................. Yes No
f. Dogsled exposure? ............................................................................................................................... Yes No
g. Downhill skiing? .................................................................................................................................... Yes No
h. Firearms or ammunition provided by applicant? ................................................................................... Yes No
i. Horse rental, training or riding instructions? ......................................................................................... Yes No
j. Inner tube rentals? ................................................................................................................................ Yes No
k. Rock climbing or rappelling? ................................................................................................................. Yes No
l. Guided saddle animal trail rides? .......................................................................................................... Yes No
m. Unguided saddle animal trail rides? ...................................................................................................... Yes No
n. Sleigh, buggy or hay rides?................................................................................................................... Yes No
o. Snowmobiles or ATVs provided by applicant?...................................................................................... Yes No
p. Tree stands provided by applicant? ...................................................................................................... Yes No
q. White water exposures (Class III and above)? ..................................................................................... Yes No
r. Use of Segways by customers? ............................................................................................................ Yes No
Comments:
7. Minimum age requirement:
8. Are hold-harmless agreements/waivers obtained from participants? ................................................. Yes No
If yes, attach sample.
9. Are all rules and safety guidelines provided to participants? .............................................................. Yes No
10. Does risk engage in the generation of power, other than emergency back-up power, for their
own use or sale to power companies?....................................................................................................
Yes No
If yes, describe:
11. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
FRAUD WARNING: 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. (Not applicable to Oregon.)
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
GLS-APP-42s (10-13) Page 2 of 4
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation 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 policy holder or claimant for
the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: 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.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any in-
surer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a
felony of the third degree.
NOTICE TO 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 sub-
ject to fines and confinement in prison.
NOTICE TO 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.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against
an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO 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 infor-
mation is guilty of a felony.
NOTICE TO RHODE ISLAND 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.
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents
a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties
under state law.
FRAUD WARNING (APPLICABLE IN 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. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
NEW YORK AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for commercial insurance or a statement of claim for any commercial or per-
sonal insurance benefits containing any materially false information, or conceals for the purpose of misleading, infor-
mation concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly
makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, dam-
age or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance
company, 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 value of the subject motor vehicle or stated claim for each violation.
GLS-APP-42s (10-13) Page 3 of 4
NEW YORK OTHER THAN AUTOMOBILE FRAUD WARNING: 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 civil penalty not to exceed five thousand dollars
and the stated value of the claim for each such violation.
APPLICANT’S STATEMENT:
I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing state-
ments are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying.
(Kansas: This does not constitute a warranty.)
APPLICANT’S SIGNATURE: DATE:
CO-APPLICANT’S SIGNATURE: DATE:
PRODUCER’S SIGNATURE: DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IOWA LICENSED AGENT:
(Applicable in Iowa Only)
NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT:
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning char-
acter, general reputation, personal characteristics and mode of living. Upon written request, additional information as to
the nature and scope of the report, if one is made, will be provided.
GLS-APP-42s (10-13) Page 4 of 4
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Outfitters and Guides Program Supplemental Application (RT Specialty)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 13 December 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document