Fillable PR GC Firearms Supplemental Application (Kinsale Insurance)

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PR GC Firearms Supplemental Application (Kinsale Insurance)

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The PR GC Firearms Supplemental Application (Kinsale Insurance) form is 5 pages long and contains:

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  • 24 check-boxes
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Page 1 of 5
FIREARMS SUPPLEMENTAL APPLICATION
COMPLETE IN ADDITION TO ACORD APPLICATIONS.
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
1)
Named Insured:
Brokerage/Broker:
Agency/Agent:
Renewal? Yes No
Policy Number:
Effective Date:
Website:
2) Current Carrier Information:
Carrier:
Limit of Insurance:
Deductible:
Premium:
Offering renewal? Yes No
Claims made? Yes No Retroactive date:
Please attach copies of the following:
a) Currently valued five year loss runs, including claim detail for all losses open or exceeding $15,000
b) Applicant’s product brochure, catalog, or marketing materials if a website is not available
c) A copy of all Federal Firearms Licenses (FFLs) held by you
3) What are your operations? Check all that apply:
Firearms, Suppressors, and Lower Receivers Manufacturing Operational Firearms Parts and Holsters Manufacturing
Manufacturing of “gray” parts –unbored/80% receivers, cheek paddles, trigger cranks Non-operational Firearms Parts Manufacturing
Accessories and Optics Manufacturing Ammunition Manufacturing
Wholesale Firearm Distribution or Military/LEO only Retail Sales Retail Civilian Firearm Sales
Body Armor/Ballistic Paneling Manufacturing Firearm Range Manufacturing
Paintball Marker Manufacturing Pellet, BB, and Airsoft Gun Manufacturing
Gumsmithing/Gun Repair (on customer supplied arms only) Firearm Range Operation
Firearms Training/Instruction Courses, Guided Hunts “Extreme” Or Tactical Shooting Courses/Ranges
Other
4) What are your sales for the coming policy term? If more than one box above is checked, please provide a breakdown
for each category:
GENERAL INFORMATION
Page 2 of 5
5) If selling any airsoft/airgun or bb/pellet gun, do all products bear a brightly colored safety tip? Yes No
If Yes, please provide maximum FPS for most powerful unit:
6) If selling any ammunition, are any products of an atypical or specialty nature Yes No
such as incendiary rounds, armor-piercing bullets, or rubber, bean bag, or pepper
less-than-lethal? If yes please list:
7) For retail firearm sales, please clarify the following:
a. Is a formal Straw Sales policy in place? Yes No
If yes, are all employees required to sign off on these policies, regardless Yes No
of full or part time status?
b. Have you or any of your employees ever been cited for a Straw Sales violation? Yes No
If yes, please attach details of the event and steps taken after.
c. Do you have a mandatory waiting period? Yes No
If yes, does this apply to all firearms or only specific types? Please list:
d. Please describe the security measures in place at your location(s):
e. If you are selling products online, do you require a dealer address and FFL to ship? Yes No
8) For range operations, please clarify the following:
a. Is your range publicly accessible? Yes No
b. Is annual range safety training required for range use? Yes No
c. Do you rent firearms for use on your range? Yes No
If yes, are first time patrons allowed to rent a firearm unaccompanied? Yes No
d. For indoor ranges, are ballistic panels and air conditioning systems Yes No
Department of Energy compliant?
e. How often are ballistic panels/backstops inspected and replaced?
f. Do you require eye and ear protection be worn at all times? Yes No
g. If you are operating an “extreme” range or course, does your operation Yes No
involve any aircraft, explosives, tanks or military vehicles? If yes, please clarify:
9) Have any products manufactured, distributed, or sold by you been involved in a mass Yes No
shooting event? If yes, please provide details:
10) For ballistic paneling other than plates and vests, are products tested by an Yes No
independent 3rd party? Please clarify to what NIJ level products are tested to:
11) Do you sell any less-than-lethal weaponry? Yes No
If yes, please list and clarify if sales are to Military/LEO, civilian, or both:
Page 3 of 5
12) Have you ever been cited for an ATF violation? Yes No
a. If yes, was your FFL suspended or revoked? Yes No
b. Please attach a copy of the ATF warning letter, any follow up letters, and details of steps taken to ensure
that violations of this nature will not occur in the future.
13) Are batch or product records, serial numbers or copies of guarantee/warranty cards Yes No
maintained that would facilitate tracing whereabouts of products? If Yes, confirm how
long these records are maintained:
14) In the event that it becomes necessary to recall a product, do you have a recall plan in place? Yes No
a. Do you have Product Recall insurance? Yes No
b. What means would be used to secure the return and disposal of the product?
15) Have you ever had a product recall event? Yes No
a. If Yes, supply the following details: Date of recall(s):
b. Voluntary? Ordered? By what agency?
c. Product(s) involved:
d. Reason for recall and how discovered:
e. What was the remedy of the problem?
f. What percentage of recalled goods were returned/repaired?
16) Are there any present situations that might give rise to an incident causing a product recall? Yes No
If Yes, supply details.
17) Have you had any Product Liability claims that were or were not covered by insurance? Yes No
If Yes, please provide details.
18) During the past five years, has any insurer ever canceled or non-renewed similar Yes No
insurance to any applicant or has your insurance been canceled for nonpayment of
premium by any insurance or finance company. If Yes, please explain.
19) Is your company aware of any occurrences, facts, circumstances, incidents, situations, Yes No
damages or accidents (including but not limited to allegations of faulty or defective products,
product failure, product dispute bodily injury or property damage) arising out of or related to
your products that a reasonably prudent person might expect to give rise to a claim or lawsuit
whether valid or not which might directly or indirectly involve the company?
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA,
NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN,
Page 4 of 5
AND WYOMING APPLICANTS: In some states, 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, for the purpose of misleading, conceals information
concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: 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 policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: 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 insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: 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.
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 subject 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 denial of insurance benefits.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
NOTICE TO NEW MEXICO 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 civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 and the stated value
of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she 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: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an application
for insurance or statement of a 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 the person to criminal and civil penalties.
NOTICE TO TENNESSEE 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 include imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA 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 include imprisonment, fines and denial of insurance benefits.
Page 5 of 5
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit
any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this
application and made a part of this application.
Applicant: Title:
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
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PR GC Firearms Supplemental Application (Kinsale Insurance)

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Completed 15 July 2020

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