Fillable PUBLIC ENTITY/ DAM SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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PUBLIC ENTITY/ DAM SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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PUBLIC ENTITY/ DAM SUPPLEMENTAL APPLICATION
PIIC Producer:
Broker:
ACCOUNT INFORMATION
Applicant Name:
Name of Structure:
Address: Year Built:
1. Built under the direction of:
Entity Dept. of Interior Dept. of Agriculture
Corp. of Engineers Bureau of Reclamation Other:
2. Purpose (check all applicable):
Flood Industrial Water Supply
Irrigation Power
If Power, please describe alternate source in event of power failure:
3. Construction:
Concrete Steel Sheet Timber
Earth (please note if it is hydraulic fill) Other:
4. Dimensions:
Acre/Feet: Top Width:
Storage Capacity (gallons): Base Width:
Height:
Additional storage available in flood state? Yes No
If “yes”, describe:
5. How many dams are located in the township / municipality?
6. Do any of these pose significant danger to surrounding area if they fail? Yes No
Comment:
7. How frequently is the dam inspected?
By Whom?
8. Has risk been included under the National Program for Dam Inspection? Yes No
Date of Last inspection on file:
Status of any recommendations made:
9. Name of tributary rivers of impoundment waters:
Upstream
Downstream
Public Entity / Dam Supplemental
Application
Page 1 of 3 4/05
Print Application
Clear Application
10 How is the water level controlled?
Gates Spillway Other:
If gates, what type?
How are the gates operated? Manual Automatic
UPSTREAM EXPOSURES
Are there exposures to any of the following:
1. Structures, Industrial Complexes, Housing? Yes No
If yes, describe (be specific: Include distances, etc.)
2. Recreational Areas (swimming, boating, camping, etc.)? Yes No
If yes, describe (be specific: Include distances, etc.):
DOWNSTREAM EXPOSURES
Must be completed for all items listed below:
Housing: Distance: Description:
Industrial Complexes: Distance: Description:
Pumping Stations: Distance: Description:
Bridges: Distance: Description:
Other Structures: Distance: Description:
Description:
Highways: Distance: Description:
Description (Interstate, State Route, Country Road, Paved, Unpaved, etc.):
Agricultural Areas: Distance: Description:
Is there exposure to:
Livestock Yes No Dwelling? Yes No
Crops Yes No Barns & Sheds? Yes No
Recreational Areas: Distance: Description:
Railroad(s): Distance: Description:
Schools: Distance: Description:
Hospitals: Distance: Description:
Camp: Distance: Description:
Maximum number of people flood could affect:
Downstream monitoring & controls:
(Please describe in detail monitoring instrumentation used, frequency of on-site visual checks,
seepage review and control, structural integrity checks, etc.)
IMPORTANT
A current Dam Engineering Report must be provided with this supplemental application to
properly evaluate the liability exposures.
Public Entity / Dam Supplemental
Application
Page 2 of 3 4/05
Print Application
Clear Application
Fraud Notice
NOTICE TO APPLICANTS: 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 MAY SUBJECT SUCH PERSON
TO CRIMINAL AND CIVIL PENALTIES.
NOTICE TO NEW YORK APPLICANTS: 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 THE
STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
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 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 MINNESOTA AND 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 NEBRASKA AND 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 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 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 FLORIDA APPLICANTS: 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 OF THE THIRD DEGREE.
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 MAINE AND 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.
NOTICE TO OREGON APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD OR SOLICIT
ANOTHER TO DEFRAUD AN INSURER: (1) BY SUBMITTING AN APPLICATION, OR (2) BY FILING A CLAIM CONTAINING A
FALSE STATEMENT AS TO ANY MATERIAL FACT, MAY BE VIOLATING STATE LAW.
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 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 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.”
Date: Insured Signature : _______________________________________
Date: Agent Signature: _________________________________________
Public Entity / Dam Supplemental
Application
Page 3 of 3 4/05
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PUBLIC ENTITY DAM SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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Completed 11 February 2021

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