Fillable PRIZE INDEMNIFICATION APPLICATION (RT Specialty)

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PRIZE INDEMNIFICATION APPLICATION (RT Specialty)

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  • 26 check-boxes
  • 74 other fields

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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
PRIZE INDEMNIFICATION APPLICATION
Applicant’s Name:
Mailing Address:
Location Address:
Web site Address:
Agency Name:
Agent:
Address:
E-mail:
Phone:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE”
Applicant is: Individual Corporation Partnership Joint Venture
Limited Liability Company Other (Specify):
A. GENERAL INFORMATION:
1. Type of Event: Hole-in-One Basketball Shoot Fishing Derby Field Goal Kick
2. Name of contest/tournament:
3. Name of location where contest/tournament to be held:
4. Number of times contest/tournament previously held:
5. Limit of Liability desired: $
6. Actual cost for prizes: $
7. Prize with be: Cash Car Other:
8. Check box that applies: Limit reinstated Limit not reinstated
9. Prior Carrier & Loss History (for last 3 years):
Year:
Year:
Year:
Carrier
Date of Loss
IMS-APP-8 (9-11) Page 1 of 5
Submit Here
B. HOLE-IN-ONE COVERAGE:
1. Number of rounds per day:
2. Number of participants:
3. How many shots does each participant have at insured hole during tournament play?
4. Size of course: 9 Hole Course 18 Hole Course
5. Are there more than four par 3 holes on the course? ..................................................................... Yes No
6. Hole(s) to be covered: No.: Length in yards: Par:
No.: Length in yards: Par:
No.: Length in yards: Par:
7. If more than one hole, is there a prize per hole? ............................................................................. Yes No
If yes, amount of coverage per hole: $
8. Any losses for specified hole(s) in the past five years? ................................................................. Yes No
If yes, describe:
Hole-In-One Coverage Conditions:
a. Hole must be at least one hundred twenty (120) yards.
b. Amateurs only. (Not eligible if contestant played or currently playing golf professionally or for any two or four
year college.)
c. A shot is a stroke as defined by the USGA Rules of Golf.
d. No mulligan’s are permitted on the selected hole(s).
e. No practice shots shall be permitted and all shots shall be made in the regular round of tournament play.
f. The Hole-In-One must occur during the specified tournament by a registered player.
g. In the event of inclement weather, the effective date of this policy may be amended to a rescheduled rain date
without additional charge.
h. One Tournament Committee Member shall be stationed at each of the selected holes at all times during the
tournament.
i. Certification of achievement shall be made by the Tournament Committee Member stationed at the selected
hole, the successful participant and the Golf Course Secretary.
j. Score cards shall be completed and submitted with the above-mentioned certification of achievement.
k. Witness requirements are based on prize value. All witnesses must be event non-participants, age
eighteen (18) or older, and appointed by event officials as follows:
(a) Prize limits up to $5,000 do not require a witness.
(b) Prize limits from $5,001 to $50,000 require one witness.
(c) Prize limits from $50,001 to $100,000 require two witnesses.
l. Once a Hole-in-One is made, the contest is over. The policy limit will not be reinstated, unless otherwise
indicated.
IMS-APP-8 (9-11) Page 2 of 5
C. BASKETBALL SHOOT COVERAGE:
1. Nature of contest/tournament: Half Court Three-Quarter Court Other, as indicated below*
*
Nature of contest/tournament if other than half court or three-quarter court shot:
2. Number of shots permitted:
Basketball Shoot Coverage Conditions:
a. Basketball court must be of regulation size ninety-four (94) feet.
b. Amateurs only. (Not eligible if contestant played or currently playing basketball professionally or for any two or
four year college.)
c. One contestant only per game, picked randomly from the audience during the game.
d. Shot(s) must be made from behind the half court line or three-quarter court line.
e. No practice shots are permitted.
f. Stadium officials or an event referee must be in attendance.
g. Once coverage is bound, the premium is fully earned.
h. Once shot(s) is made, the contest is over. The policy limit will not be reinstated, unless otherwise indicated.
D. FISHING DERBY COVERAGE:
1. Nature of contest/tournament: Tagged Fish Record Fish Other, as indicated below*
*Nature of contest/tournament if other than one (1) tagged fish or record fish:
2. Acreage of lake:
3. Number of participants:
4. Hours and Date(s) of tournament: on
5. All coverage shall be rendered NULL and VOID as of on .
Any claim to the prize must be reported to the official no later than on .
6. For record fish: What is the current state record for the type of fish?
Fishing Derby Coverage Conditions:
a. Tagged Fish
(1) Only one (1) fish will be tagged, unless indicated differently above*.
(2) Tournament must be supervised by local Fish and Game Department personnel.
(3) Releasing of the tagged fish will be supervised by local Fish and Game Department personnel. The
named insured and the official from the local Fish and Game Department shall be the only persons with
access to or knowledge of the location and time of the release of the fish.
(4) Anyone related to or employed by the named insured, sponsor, official or person releasing the fish is not
eligible to enter the contest.
b. Record Fish
(1) Only live fish and fish caught during contest hours within the tournament boundaries are eligible.
IMS-APP-8 (9-11) Page 3 of 5
E. FIELD GOAL COVERAGE:
1.
Describe nature of contest:
2. Number of yards to goal posts:
3. Number of participants:
4. Number of kicks per participant:
Field Goal Kick Coverage Conditions:
a. Football field must be regulation size one hundred twenty (120) yards.
b. Amateurs only. (Not eligible if contestant played or currently playing football or soccer professionally or for
any two or four year college.)
c. Participant(s) randomly picked from the audience during the game.
d. No practice kicks.
This application does not bind YOU nor US to complete the insurance, but it is agreed that the information 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 Nebraska, Oregon or Vermont).
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 ad-
dition, 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 and willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly and 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.
IMS-APP-8 (9-11) Page 4 of 5
NOTICE TO OHIO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company 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.
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 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.
FRAUD WARNING APPLICABLE IN THE STATE OF 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 also be subject to a civil penalty not to exceed five thousand dollars
and that stated value of the claim for each such violation.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: _______________________________________________________ DATE:
(Must be signed by an active owner, partner or executive officer)
PRODUCER’S SIGNATURE: ______________________________________________________ DATE:
IMS-APP-8 (9-11) Page 5 of 5
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Completed 13 December 2020

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