Fillable PAINTBALL SUPPLEMENTAL APPLICATION* (Philadelphia Insurance Companies)

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PAINTBALL SUPPLEMENTAL APPLICATION* (Philadelphia Insurance Companies)

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PAINTBALL SUPPLEMENTAL APPLICATION*
*to accompany the General Application
Named Insured:
Risk Management Contact:
Risk Management’s Phone:
Risk Management Email:
GENERAL INFORMATION
1.
Location of Operation:
2.
Annual Gross Receipts from Admissions:
Estimated This Season: $
3.
Please list any associations of which the Applicant is a member:
4.
Does the Applicant own or lease this premise?
5.
Number of years in business at this location:
years
6.
Number of years in business management:
years
7.
Total experience in this type of business:
years
8.
Does the Applicant hold a PTI certification?
Yes
No
a.
If yes:
C1
C2
C3
C4
C5
C5A
C6
b.
If yes: ID number:
9.
Does the Applicant sell equipment?
Yes
No
a.
If yes: Annual Sales: $
b.
Please describe what type of equipment:
10.
Does the Applicant sell used equipment?
Yes
No
a.
If yes: Annual Sales: $
b.
Please describe what type of equipment:
11.
Does the Applicant sell equipment on the internet?
Yes
No
a.
If yes: Annual Sales: $
b.
Website address: www.
12.
Does the Applicant repair equipment?
Yes
No
a.
If yes: Annual Sales: $
b.
Please describe what types of repairs are performed:
c.
Are repairs performed by a PTI Graduate?
Yes
No
13.
Does the Applicant have a snack bar or restaurant?
Yes
No
a.
If yes: Annual Sales: $
b.
Food: $
Liquor: $
SAFETY AND TRAINING INFORMATION
1.
Is the Applicant in compliance with APL Safety Guidelines?
Yes
No
2.
Are safety rules and procedures clearly posted on the premises?
Yes
No
3.
Does the Applicant have participants sign a release of liability or waiver prior to play?
Yes
No
If yes, please provide a copy of the document.
4.
Are alcoholic beverages allowed on the premises?
Yes
No
5.
Is approved Paintball Sports eye protection required to be worn by all players?
Yes
No
6.
How often is the Applicant’s equipment tested and velocity checked?
Paintball Supplemental
Page 1 of 3
© 2018 Philadelphia Consolidated Holding Corp.
11/2018
Clear Application
Print Application
7.
Where are Co2 tanks stored?
8.
How are Co2 tanks secured?
9.
Minimum age of participants: years
No one under the age of 10 allowed, if under 21 additional supervision required.
10.
Is customer’s equipment checked before use to assure that it meets minimum safety requirements?
Yes
No
11.
Is a documented safety orientation provided to all participants prior to play?
Yes
No
STAFF INFORMATION
1.
Is supervision provided at all times?
Yes
No
2.
Is the supervision provided by a first-aid and CPR certified staff member?
Yes
No
3.
Do all staff members understand the safety rules?
Yes
No
FACILITY INFORMATION
1.
Type of paintball operation:
Playing Field
Sports Camp
Sports Tournament
2.
What is the total acreage or square feet of the Applicant’s property?
3.
What is the total square feet for game fields?
4.
What is the total square feet for public parking?
5.
Is the facility enclosed or fenced?
Yes
No
6.
Can the facility be locked?
Yes
No
7.
Length of season:
8.
Operating hours:
9.
Number of field locations:
Indoor:
Outdoor:
10.
Maximum number of players per field:
Indoor:
Outdoor:
11.
Total estimated number of players per year: (Avg daily attendance x game days per yr.)
12.
Range of velocity of paint pellets:
feet per second
13.
Are spectators allowed on the premises?
Yes
No
14.
Are players allowed to use their own guns?
Yes
No
15.
Are players allowed to use their own safety equipment?
Yes
No
16.
Are any paintball games conducted on horseback?
Yes
No
17.
Are paintball mines or grenades allowed?
Yes
No
If yes, are there rules concerning their use?
Yes
No
18.
Does the Applicant have any climbing structures?
Yes
No
a.
If yes, do they have handrails?
Yes
No
b.
Please describe:
19.
Are night games held?
Yes
No
a.
If yes, please describe lighting:
20.
Are games refereed?
Yes
No
a.
If yes, by whom?
Paintball Supplemental
Page 2 of 3
© 2018 Philadelphia Consolidated Holding Corp.
11/2018
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
SECTION 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)
Paintball Supplemental
Page 3 of 3
© 2018 Philadelphia Consolidated Holding Corp.
11/2018
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PAINTBALL SUPPLEMENTAL APPLICATION* (Philadelphia Insurance Companies)

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Completed 29 July 2020

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