Fillable PRO SPORTS VENUES AND SPORTS TEAMS APPLICATION (Philadelphia Insurance Companies)

Fill Online, Printable, Fillable, Blank PRO SPORTS VENUES AND SPORTS TEAMS APPLICATION (Philadelphia Insurance Companies) Form

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

PRO SPORTS VENUES AND SPORTS TEAMS APPLICATION (Philadelphia Insurance Companies)

On average this form takes 143 minutes to complete

The PRO SPORTS VENUES AND SPORTS TEAMS APPLICATION (Philadelphia Insurance Companies) form is 18 pages long and contains:

  • 0 signatures
  • 111 check-boxes
  • 522 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Philadelphia Insurance Companies forms online.

BROWSE PHILADELPHIA INSURANCE COMPANIES 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
 
PRO SPORTS VENUES AND SPORTS TEAMS APPLICATION
SUBMISSION REQUIREMENTS
• Complete ACORD Property, Auto and Umbrella Liability if coverages requested
• Lease agreement between the insured and venue / facility owner (if applicable)
• Standard contract for the lease of the insured’s venue / facility to others
• Contracts with and certificates of insurance from the sub-contractors listed in Question 2 of the
General Liability section
• Complete annual event schedule
• Emergency evacuation plan (if the insured manages or operates the venue)
• Latest financial statement
• Currently valued insurance company loss runs for the current policy period plus 4 prior years
If Team, also include: (1) Sample Player Agreement
(2) Contract between the Team and the League
• If Abuse coverage is requested a copy of the Applicant’s Sexual Abuse Prevention Policy is required
GENERAL INFORMATION
1.
Applicant name:
2.
Name of facility:
3.
Mailing address:
Physical address:
4.
Does the Applicant own or lease the facility?
Own
Lease
5.
Contact person: Telephone:
Contact e-mail address: Web site address: www.
6.
Business type:
Partnership
Individual
Governmental entity
Other:
7.
Year business was established?
Number of years under present management:
FEIN:
8.
List all Named Insureds and their interests:
Note: All First Named Insureds requires common / majority ownership of the Named Insured.
If not, please explain.
a.
b.
c.
d.
e.
Explanation:
9.
Operations
a.
Is the Applicant a venue only?
Yes
No
b.
Is the Applicant a team only?
Yes
No
If yes, please complete the TEAM section below.
c.
Is the Applicant a team that also manages the venue?
Yes
No
If yes, please complete the TEAM section below.
10.
Does the Applicant have any inflatable, fabric or air supported structures such as, but not limited
to, bubbles or domes?
Yes
No
Pro Sports Venues and
Sports Teams Application
Page 1 of 12
© 2018 Philadelphia Consolidated Holding Corp.
05/2018
Clear Application
Print Application
TEAM (IF APPLICABLE) N/A
1.
Player Status: Are players
Employed
Independent Contractors
If employed:
By Team
By League
2.
Does the league require that all teams carry Workers Compensation for all players?
Yes
No
3.
If not covered by Workers Compensation, are all players in the league covered by a separate
Participant Accident policy?
Yes
No
4.
Does the Applicant conduct any amateur leagues, teams, camps, clinics or tournaments?
Yes
No
If yes,
a.
Does the Applicant carry separate Participant Accident Medical Coverage?
Yes
No
If yes, what limit is in place: $
b.
Annual number of amateur camper days (number of camp and tournament participants X
number of days they attend):
c.
Annual number of amateur league and team participants (including jr. teams, academy
teams, etc.):
GENERAL LIABILITY
1.
Annual number of turnstile attendees (all events):
Total seating capacity:
Annual payroll: $
Number of employees:
Sales / Receipts
a.
Food / Restaurant:
$
b.
Liquor:
$
c.
Gift Shop:
$
Describe:
d.
Parking:
$
e.
Other:
$
Describe:
2.
Please specify who has responsibility for the following event day operations:
Owner
Insured
Sub-Cont
Other (describe)
a.
Facility maintenance
b.
Food concessions
c.
Liquor
d.
Gift Shop
e.
Parking
f.
Security (complete page 4 if Applicant)
g.
First Aid
h.
Fireworks / Pyrotechnics
i.
Inflatables / Amusement devices
j.
Off premises catering / events
Explain all “Other” answers below:
3.
Regarding contracts and certificates of insurance with sub-contractors and tenants:
Insured
Sub/Tenant
Mutual
Neither
a.
Indemnification / Hold harmless wording in favor of:
b.
Additional insured status in favor of:
c.
Minimum insurance limits of $1,000,000?
d.
Is a certificate of insurance required?
4.
If temporary seating, type:
Inspected prior to each event?
Yes
No
5.
Any self-promoted or co-promoted events? If yes, attach a schedule.
Yes
No
6.
Are any other child care services provided? If yes, provide details:
Yes
No
7.
Coverage limits requested
Limit
Each Occurrence / Each Claim
$
General Aggregate
$
Products / Completed Operations Aggregate
$
Personal / Advertising Injury
$
Damage to Premises Rented to the Applicant
$
Pro Sports Venues and
Sports Teams Application
Page 2 of 12
© 2018 Philadelphia Consolidated Holding Corp.
05/2018
Clear Application
Print Application
Liquor Liability
$
Stop Gap
$
States:
Payroll by State: $
Employee Benefits Liability:
$
Employed benefits administrator
Yes
No
Current carrier:
Limit: $
Retroactive date:
Other: (specify)
$
Other: (specify)
$
Deductible: $
Self-Insured Retention: $
Self-Funded Retention: $
CONCUSSIONS - ATHLETICS
1.
Does the Applicant have a written concussion awareness and management program in place,
and, where applicable, is it compliant with current state legislation?
Yes
No
If yes, does this include:
a.
Understanding a concussion and the potential consequences of this injury?
Yes
No
b.
Recognizing the signs and symptoms of a concussion or other closed head injury and
how to respond?
Yes
No
c.
Learning about steps for returning to activity after a concussion?
Yes
No
d.
Focusing on prevention and preparedness to help keep participants safe?
Yes
No
*A copy of written program is required upon binding.
2.
Does the insured require all coaches, instructors, and officials to complete the online
Concussion Course offered by the Centers for Disease Control and Prevention?
Yes
No
3.
a.
Does the insured communicate and distribute education materials to participants and / or
parents / guardians of minors about the nature of risk of concussions, including but not
limited to how to recognize concussion symptoms, in written or electronic form?
Yes
No
b.
Does the insured require the participants and / or parents / guardians of minors to sign an
acknowledgment that they have received and reviewed?
Yes
No
4.
If a concussion is suspected, does the Applicant require the participant to leave the game or
practice immediately?
Yes
No
5.
Does the Applicant mandate that participants suspected of suffering a concussion can only
return after at least 24 hours and with written clearance from a licensed physician before being
allowed to return to play?
Yes
No
6.
Does the Applicant utilize base line testing?
Yes
No
7.
Does the Applicant currently utilize any concussion impact monitoring technology?
Yes
No
If yes:
a.
Describe:
b.
Advise the name of the manufacturer:
c.
Advise who monitors the data:
Coaches
Employees
Volunteers
3
rd
Party
LIFE SAFETY
1.
Is there a risk manager on premises?
Yes
No
2.
Sprinklered?
Yes
No
Percent Sprinklered: %
3.
Central station fire alarm?
Yes
No
Central station burglar alarm?
Yes
No
Surveillance cameras?
Yes
No
4.
Cooking facilities on premises?
Yes
No
If yes, automatic extinguishing system over deep fat fryers, grills & stoves?
Yes
No
How often are hood / ducts cleaned?
By whom?
Insured
Sub-contractor
If by sub-contractor, how often are they serviced?
Date last serviced?
5.
Does the Applicant have Automated External Defibrillators (AEDs)?
Yes
No
Pro Sports Venues and
Sports Teams Application
Page 3 of 12
© 2018 Philadelphia Consolidated Holding Corp.
05/2018
Clear Application
Print Application
If yes, are staff members trained to use it?
Yes
No
6.
How many means of egress:
Are all exits clearly marked?
Yes
No
Are all doors equipped with panic hardware?
Yes
No
7.
Does the Applicant have backup emergency lighting and / or emergency generators in the
event of a power failure?
Yes
No
8.
Does the Applicant have an emergency evacuation plan? (If yes, attach a copy)
Yes
No
Evacuation procedures and floor plans posted?
Yes
No
9.
Are parking lots well lit?
Yes
No
Patrolled by security?
Yes
No
10.
Date of last major construction on facility (structural):
11.
Any structural or major maintenance projects planned during policy term?
Yes
No
If yes, please describe and provide cost of renovations:
ABUSE OR MOLESTATION
N/A
A COPY OF THE APPLICANT’S SEXUAL ABUSE PREVENTION POLICY IS REQUIRED
1.
Does the Applicant have a written policy specifically defining and prohibiting grooming
behaviors?
Yes
No
If yes:
a.
Is this policy communicated and confirmed in writing to all employees, volunteers, and/ or
independent contractors that have access to children?
Yes
No
b.
Does the policy prohibit contact with minor participants outside of the Applicant’s
operations (including social media)?
Yes
No
Comments:
2.
Does the Applicant conduct documented sexual abuse awareness training for all of the following
that have access to children?
a.
Employees
Yes
No
b.
Volunteers
Yes
No
c.
Independent Contractors
Yes
No
IF YES, PLEASE SUBMIT A WRITTEN COPY OF THE TRAINING DOCUMENT.
Comments:
3.
Does the Applicant specifically train their hiring manager(s) with respect to detecting high risk
behaviors/ responses in the hiring process?
Yes
No
4.
Does the Applicant perform criminal background checks for all:
a.
Employees
Yes
No
b.
Volunteers
Yes
No
c.
Independent Contractors
Yes
No
Comments:
5.
In addition to criminal history question(s), does the Applicant’s employment application(s) for
employees, volunteers, and independent contractors contain question(s) to elicit high risk
responses specific to child sexual abuse?
Yes
No
6.
Does the Applicant allow any one-on-one opportunity between employees, volunteers and/ or
independent contractors and the children they serve?
Yes
No
If yes, please describe:
7.
Does the Applicant have any operations where employees, volunteers and/ or independent
contractors will be physically touching another person?
Yes
No
If yes, please describe:
Pro Sports Venues and
Sports Teams Application
Page 4 of 12
© 2018 Philadelphia Consolidated Holding Corp.
05/2018
Clear Application
Print Application
8.
Does the Applicant have formal sexual abuse reporting procedures in place for all players,
employees, volunteers and/ or independent contractors?
Yes
No
9.
Has the Applicant ever had an incident which results in an allegation of sexual abuse?
Yes
No
If yes, please describe:
SECURITY
N/A
(Complete only if security is the responsibility of the insured)
Part I:
1.
Who is primarily responsible (via contract) for liability coverage for security personnel?
Insured?
Municipality?
Subcontractor?
2.
Employed or sub-contracted security personnel?
Employed
Sub-contracted
“Employed” is defined as individuals being paid and supervised directly by the insured. “Contract” is defined as the
existence of a written contract with another entity for security services that has separate insurance coverage and
provided a certificate naming the Insured as Additional Insured with limits equal to or greater than the Insured.
3.
Number and payroll of employed security personnel:
Unarmed: #
Payroll: $
Armed (not including off duty police officers): #
Payroll: $
Off duty police officers: #
Payroll: $
4.
Sub-contracted security – cost of sub-contract: $
5.
Total maximum hours per day permitted at this and all other places of employment:
Total maximum hours per week:
6.
What are the staffing guidelines per number of patrons?
Are the guidelines determined by:
Ordinance?
Yes
No
Statute?
Yes
No
Industry standard?
Yes
No
Other: (describe)
7.
Is there a procedure to immediately report all incidents to the facility manager? If yes,
describe:
Yes
No
8.
Does the supervisor make personal contact with each security person at least once during each
shift? If yes, describe:
Yes
No
9.
Does the procedure include contacting previous employers over the previous five (5) years?
Yes
No
10.
Does the Applicant contact at least three (3) personal references?
Yes
No
11.
Is completion of a minimum twenty (20) hours initial training program required
before deployment?
Yes
No
12.
Who conducts the training and what are the trainer’s qualifications:
13.
Is a minimum of ten (10) hours on-site training required?
Yes
No
14.
Is a minimum of four (4 )hours of annual refresher or continuing education training planned and
conducted for each security employee?
Yes
No
15.
Is each security person given a personal copy of the training / safety manual?
Yes
No
If yes, has each security person given management a written acknowledgment of the policies
and contents?
Yes
No
NOTE: PLEASE INCLUDE A COPY OF THE MANUAL AND A SAMPLE OF THE WRITTEN ACKNOWLEDGEMENT.
No
No
Yes
Yes
Yes No
Pro Sports Venues and
Sports Teams Application
Page 5 of 12
© 2018 Philadelphia Consolidated Holding Corp.
05/2018
Clear Application
Print Application
Part II:
ARMED SECURITY EMPLOYEES:
1.
Are the security personnel in uniform? If yes, describe the uniform:
Yes
No
2.
Are the security personnel identified by anything other than a uniform?
Yes
No
If yes, describe the identification & include an example or photograph.
3.
Are psychological screen profiles used?
Yes
No
If yes, specify type:
4.
Are criminal background checks completed?
Yes
No
If yes, what agency is utilized?
5.
Please indicate any equipment carried or routinely available to security personnel:
Flashlight
Type:
Size:
Construction:
Handcuffs
First Aid Kit (including blood borne pathogen kit)
Nightstick
Is night stick police regulation or other:
Taser / Phaser
Chemicals (Mace, pepper gas)
Other:
Firearm – Caliber:
.357
.38
.9mm
Other:
Make:
Colt
S&W
Ruger
Cover Holster - Type:
6.
Is the ammunition:
Standard
Other:
7.
Are firearm and ammunition approved and inspected by management or the security company?
Yes
No
8.
Describe capabilities of each guard for constant communications with each other, the
supervisor, and management:
9.
Are dogs used in the Applicant’s security operations?
Yes
No
If yes, provide the type of dogs(s), number, and describe duties.
LIQUOR LIABILITY
1.
Is liquor license in the Applicant’s name?
Yes
No
If no, what is the name on the license and their relationship to the insured:
Liquor license number:
Class of license:
2.
Is the liquor service sub-contracted to a third party?
Yes
No
If yes, provide limits of liability maintained by the sub-contractor:
Is the Applicant listed as Additional Insured under sub-contractors Liquor liability coverage?
Yes
No
Is contingent liquor liability coverage requested by Insured?
Yes
No
3.
Has the Applicant’s liquor license ever been revoked or suspended? If yes, explain:
Yes
No
4.
Has the Applicant incurred claims for liquor liability during the last three (3) years?
Yes
No
If yes, explain:
5.
Has any insurer cancelled or non-renewed coverage during the last three (3) years?
Yes
No
If yes, explain:
6.
Has the Applicant ever been fined by Alcoholic Beverage Control or other
governmental regulator? If yes, explain:
Yes
No
7. Type of beverages sold:
Annual gross sales
Liquor Sales: $
Food Sales: $
Other: $
Explain:
Pro Sports Venues and
Sports Teams Application
Page 6 of 12
© 2018 Philadelphia Consolidated Holding Corp.
05/2018
Clear Application
Print Application
8.
Are patrons allowed to carry alcoholic beverages onto the premises?
Yes
No
If yes, what type?
9.
Does the Applicant exercise the right to search and seizure contraband items?
Yes
No
If yes, how does the Applicant notify the public of this?
10.
Does the Applicant maintain security personnel at entry check points? If yes, what type?
Yes
No
11.
Are the alcohol sales and consumption contained within one fixed site, or are booths / stands
located throughout the event site?
12.
Number of servers used:
Are they professional servers? If yes, explain:
Yes
No
Are they volunteer servers? Explain:
Yes
No
13.
Do the servers receive any type of alcohol awareness training? If yes, explain:
Yes
No
14.
Median age of liquor customers:
21-25
25-30
30-40
40 and over
15.
Are minors allowed to enter the location where alcohol is being served?
Yes
No
If yes, how is underage consumption of alcohol prevented?
16.
Explain how ID’s are checked:
17.
Are uniformed police officers present at the site of alcohol sales?
Yes
No
Are undercover police officers present?
Yes
No
Are private security officers present?
Yes
No
Average number of officers present at site:
18.
Are rules and regulations clearly displayed for patrons viewing? Explain:
Yes
No
19.
Is there a limit placed on the quantity of alcoholic beverages purchased at one time?
Yes
No
Explain:
20.
Is the parking area patrolled to prevent intoxicated drivers from leaving the premises?
Yes
No
Explain:
21.
Is there any type of designated driver program?
Yes
No
Explain:
22.
Limit of liquor liability coverage requested: $
PYROTECHNICS N/A
(Complete if coverage is requested for Pyrotechnics Coverage [not including flashboxes])
1.
Limit of liability requested:
$1,000,000
Other:
2.
Description of events:
3.
Location of events:
4.
Dates of events:
5.
Who is the authority having jurisdiction over the use of pyrotechnics at the Applicant’s facility:
Local Fire Department
State Fire Marshal
Other: (please list)
Pro Sports Venues and
Sports Teams Application
Page 7 of 12
© 2018 Philadelphia Consolidated Holding Corp.
05/2018
Clear Application
Print Application
6.
What permit process must be followed prior to use of pyrotechnics at the Applicant’s facility?
7.
Has the Applicant staged pyrotechnic displays before?
Yes
No
If yes, list any claims / losses that have occurred and the amount of loss.
Description
Date of Occurrence
Amount of Loss
a.
$
b.
$
c.
$
8.
Who will be the pyrotechnics operator:
Named Insured
Contractor
Complete this section if the Pyrotechnics Operator is the Named Insured
a. List the names of people shooting and describe their experience below.
Please note: This coverage will exclude bodily injury liability to the fireworks shooter.
Name
Experience
b.
Where are the pyrotechnics stored when not in use:
c.
Does it meet federal / state storage regulation?
Yes
No
d.
What quantity of pyrotechnic material is stored on site: (number of shows, pounds etc.)
e.
Describe the type of show and amount of pyrotechnics used in recurring events:
f.
Describe what fire prevention and suppression measures are taken to support the pyrotechnic
loading and firing process:
g.
Does the Applicant secure proper pyrotechnic permits for each event?
Yes
No
h.
Are the shooters listed above licensed for pyrotechnics?
Yes
No
Complete this section if the Pyrotechnics Operator is a Contractor
a.
Name:
b.
Is there an agreement with the contractor? If yes, provide a copy of the agreement.
Yes
No
c.
Will liability coverage be provided by the pyrotechnics contractor?
Yes
No
If yes, please indicate limits of coverage provided:
$1,000,000
Greater than $1,000,000
Other: $
Please attach a copy of certificate of insurance including any additional insured listing.
d.
Does the Applicant confirm that the contractor has secured the proper pyrotechnic
permits for each event?
Yes
No
e.
Describe what fire prevention and suppression measures are taken to support the pyrotechnic
loading and firing process:
f.
Does the Applicant allow tenant users (including temporary tenant users) to conduct
pyrotechnic displays either themselves or through a contractor?
Yes
No
If yes, what steps are taken to ensure that the appropriate permits are granted, appropriate fire safety
codes are met, and that insurance has been obtained from either the tenant or the tenant’s contractor
which lists the Applicant as an additional insured?
If no, does the tenant lease / use agreement indicate that pyrotechnic displays are not
permitted?
Yes
No
g.
Are events with pyrotechnics held:
Indoor
Outdoor
Pro Sports Venues and
Sports Teams Application
Page 8 of 12
© 2018 Philadelphia Consolidated Holding Corp.
05/2018
Clear Application
Print Application
h.
What type of pyrotechnics will be displayed(as defined in NFPA code 1126)
Aerial Shells
Airbursts
Black Powder
Comets
Concussion Effects
Concussion Mortars
Electric Matches
Flares
Flash Pots
Flashpower
Gerbs
Integrals Mortars
Mines
Mortars
Rockets
Saxons
Wheels
Salutes
Waterfall, Falls, Park Curtains
Other, please list:
OUTDOOR PYROTECHNICS (Only complete if indoor pyrotechnic displays are staged)
1.
Are the events in compliance with NFPA 1123 or 1126? (Code for fireworks display)
Yes
No
2.
Is there fencing to keep spectators away from restricted areas during the fireworks shooting?
Yes
No
If yes, distance of spectator fencing from launch site:
Distance of spectator parking area from launch site:
Distance of closest building or structure from launch site:
3.
Will there be firefighting equipment on site during the event?
Yes
No
If no firefighting equipment on site, give distance to nearest fire station:
4.
Will the Applicant have an ambulance on site?
Yes
No
If no, what is the estimated response time of an ambulance:
If no, what is the distance to nearest medical facility:
INDOOR PYROTECNICS (Only complete if indoor pyrotechnic displays are staged)
1.
Are the events in compliance with code NFPA 1126?
Yes
No
(Standard code for the use of pyrotechnics before a proximate audience)
2.
Is the facility sprinklered?
Yes
No
3.
What other form of fire fighting equipment is available at the facility:
4.
Does the facility have an emergency evacuation plan?
Yes
No
If yes, how often is the staff drilled on emergency evacuation:
5.
Number of accessible (not locked) emergency exits at the facility:
6.
What steps are taken to inform patrons of the locations of all emergency exits:
7.
Maximum capacity of the facility:
8.
Has the fire marshal approved the use of pyrotechnics at the facility?
Yes
No
If yes, as of what date:
HIRED & NON-OWNED AUTO NA
1.
Does the Applicant have any owned automobiles?
Yes
No
NOTE: If insured has owned autos, the hired car and non-owned auto coverage should be placed with the
automobile carrier. Explain if an exception is requested.
2.
Does the Applicant allow employees to use their own personal vehicles for its business
purposes?
Yes
No
If yes, how many employees use their own personal vehicles:
If yes, how often?
Daily
Weekly
Monthly
Other:
3.
Does the Applicant obtain Motor Vehicle Reports?
Yes
No
If yes, how often?
Annually
Every other year
Other:
4.
Does the Applicant confirm that all employees who regularly use their cars for business
purposes carry minimum personal auto limits?
Yes
No
If yes, what minimum limits are required: $
5.
Please provide the approximate cost of hire for all hired or leased autos during the course of the policy period:
$
6.
Is hired auto physical damage required?
Yes
No
If yes, what is the maximum value of hired vehicle the Applicant would like insured? $
NOTE: Physical Damage deductibles: $100 comprehensive / $1,000 collision provided.
Pro Sports Venues and
Sports Teams Application
Page 9 of 12
© 2018 Philadelphia Consolidated Holding Corp.
05/2018
Clear Application
Print Application
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
SE
CTION 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)
Pro Sports Venues and
Sports Teams Application
Page 10 of 12
© 2018 Philadelphia Consolidated Holding Corp.
05/2018
Clear Application
Print Application
.
CYBER SECURITY LIABILITY ENDORSEMENT – SUPPLEMENTAL
QUESTIONNAIRE
Name of Applicant:
Address of Applicant:
City: State: Zip:
Website: www:
Nature of Operations:
1. Annual sales or revenue: $
2. Does the Applicant collect, store or otherwise handle any Personally Identifiable Information (PII)
belonging to customers, clients, or other third parties, other than employees?
If yes, please indicate the types of Personally Identifiable Information held (check all that apply):
Yes No
a. Social Security Numbers, Bank or Other Financial Account Details, Driver’s License or
other State Identification Numbers
b. Non-public Medical or Healthcare Data, including Protected Health Information (PHI)
c. Credit or Debit Card Information
3. a. During the last three (3) years, has anyone alleged that the Applicant was responsible for
damage to their computer system(s) arising out of the operation of the Applicant’s computer
system(s)?
Yes No
b. During the last three (3) years, has anyone made a demand, claim, complaint, or filed a
lawsuit against t
he Applicant alleging
invasion or interference of rights of privacy or the
inappropriate disclosure of Personally Identifiable Information (PII)?
Yes No
c. During the last three (3) years, has the Applicant been the subject of an investigation or
action by any regulatory or administrative agency for privacy-related violations?
Yes No
d. Is the Applicant aware of any circumstance that could reasonably be anticipated to result in a
claim being made against them for the coverage being applied for?
Yes No
PI-CYBE-APP (11/16)
Page 1 of 2
Clear Application
Print Application
Clear Application
Print Application
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)
PI-CYBE-APP (11/16)
Page 2 of 2
Clear Application
Print Application
Clear Application
Print Application
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

PRO SPORTS VENUES AND SPORTS TEAMS APPLICATION (Philadelphia Insurance Companies)

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 29 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document