Fillable RETAIL ARCHERY AND RANGE APPLICATION (Philadelphia Insurance Companies)

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RETAIL ARCHERY AND RANGE APPLICATION (Philadelphia Insurance Companies)

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RETAIL ARCHERY AND RANGE APPLICATION
SUBMISSION REQUIREMENTS
• All brochures describing any and all services; or website address.
• The liability waiver / hold harmless agreement you require your guests to sign, if applicable.
• Currently valued insurance company loss runs for the current policy period plus 3 prior years
if unavailable, provide a no loss letter signed by the insured.
•
ACORD forms for other lines requested (Property, Inland Marine, Crime, etc.)
GENERAL INFORMATION
Limit of Liability requested: $ 300,000 Occurrence
$ 500,000 Occurrence
$1,000,000 Occurrence
1. Do you operate any other business from this location? Yes No
(List information below for each business, use a separate sheet to list information if necessary)
If yes, type of entity: Corporation Partnership Individual LLC Other:
Description of business:
2. Do you have separate insurance for this business? Yes No
PRIOR CARRIER INFORMATION
Insurance Carrier Limits of Liability Premium
Last Year
Two Years Ago
Three Years Ago
ADDITIONAL INSUREDS, if necessary use another sheet of paper
Name Complete Address Interest
PRODUCING INSURANCE AGENT
AGENCY:
CONTACT:
ADDRESS:
TELEPHONE: FAX:
E-MAIL:
THIS IS AN APPLICATION FOR INSURANCE. THIS IS NOT A BINDER OF INSURANCE.
State: Zip:
County: State: Zip:
Fax Number:
Risk Management’s Phone:
Corporation Partnership Individual LLC Other:
Named Insured:
Principal Contact:
Mailing Street Address:
Mailing City:
Location Street Address:
Location City:
Phone Number:
Website: www.
Risk Management Contact:
Risk Management Email:
Business Type:
Effective Date:
Retail Archery and Range Application
Page 1 of 5
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
Print Application
Clear Application
N/A
Location Information
. Please review building security measures listed below:
Fire Alarm:
Yes
No
Central Local
Burglar Alarm:
Yes
No
Is the alarm UL listed or approved?
Yes
No
Central Local
Smoke Detectors:
Yes
No
Battery Hardwired
. Doors are: Metal Glass Frame
. Do windows and glass doors have metal bars?
Yes
No
. Describe other protection: (safe, dead bolt locks, metal bars, crash barriers in front of
building, fire extinguishers, etc.)
. If your building is more than ten (10) years old, what year was the last time wiring,
plumbing and heating / AC were updated and / or serviced?
. Does the building have other occupancies?
Yes
No
If yes, describe:
. Are there any additional locations to be covered?
Yes
No
If yes, please provide complete address and describe:
. Are all activities and locations to be covered in full compliances with applicable
federal, state and local regulations?
Yes
No
. Is the building within city limits?
Yes
No
1. Is the building 100% sprinklered?
Yes
No
1. What is the distance to the nearest fire hydrant?
RETAIL OPERATIONS
N/A
1.
Estimated gross revenue for the next twelve (12) months:
$
Revenues from axe throwing ranges:
$
Revenues from archery ranges:
$
Revenues from sale of sporting goods:
$
Other revenue, describe:
$
2.
Are all of your products purchased from U.S. manufacturers or distributors?
Yes
No
If no, % are directly imported by your from foreign company.
% are purchased from foreign wholesaler/distributor.
If no, and you are a direct importer, are you named on a foreign manufacturer’s
insurance policy for vendors liability coverage?
Yes
No
If yes, please provide a copy of the endorsement.
3.
If you are a wholesaler or distributor, are you named on a U.S or foreign
manufacturer’s or importer’s insurance policy for vendors liability coverage?
Yes
No
4.
What is the total value of retail inventory?
$
Retail Archery and Range Application
Page 2 of 5
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
Clear Application
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5.
Provide the average number of products in your inventory for the types listed below:
New
Used or Consignment
Total
#
Total
#
Crossbows
#
Crossbows
#
Compound Bows
#
Compound bows
#
Bows
#
Bows
#
Parts/ Accessories
#
Parts/ Accessories
#
Sporting Goods
#
Sporting Goods
#
6.
Do you sell by mail order?
Yes
No
If yes, describe all products sold or provide us with your catalog:
7.
Do you sell over the internet?
Yes
No
If yes, describe all products sold or provide us with your internet address:
RANGE OPERATIONS N/A
1. 7\SHRI5ange
2. Is the range in compliance with any recognized standards? (i.e. ATA.) Yes No
3. Does the range have any age restrictions? Yes No
If yes, please describe:
Indoor Range?
Yes
No
Number of Lanes:
Outdoor Range
Yes
No
Number of Lanes / Stations:
Maximum Distance Shot:
4
Axe Throwing?
Yes
No
a.
Is a supervisor on duty at all times?
Yes
No
b.
Are supervisors first aid certified?
Yes
No
c.
Are waivers mandatory? (Please provide a copy)
Yes
No
d.
What are the age restrictions for axe throwers?
Clients / Shooters
1.
Is club membership required?
Yes
No
2. Is a questionnaire used to obtain information on the shooter’s name, age, health, or
shooting experience? If yes, attach a copy.
Yes
No
3.
Are shooters required to sign liability waivers? If yes, attach a copy.
Yes
No
4.
Are shooter-owned bows inspected at check in?
Yes
No
If yes, by whom:
5.
Are eye and ear protection mandatory?
Yes
No
6.
How often are strings changed / checked on rental bows?
Range Supervision
1.
Is a supervisor on duty at all times?
Yes
No
2.
Number of range supervisors:
3.
Type of certification of range supervisors:
4.
Do you have written rules prominently displayed?
Yes
No
Archery
Axe
Firearm
Retail Archery and Range Application
Page 3 of 5
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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5.
Do you provide lessons?
Yes
No
If yes, provide qualifications of instructors:
6.
Do you provide rental or loaner firearms?
Yes
No
MANAGEMENT
1.
Years in business:
2.
Years at location:
3. Are there written safety policies, procedures or rules for staff / employees and / or
shooters?
Yes
No
4.
Does range have a public address system that all shooters can hear?
Yes
No
5.
Are first aid kits located on each range?
Yes
No
6.
Number of employees with Medic First Aid Certification:
7.
Will any tournaments or “Spectator Special Events”: be held this year?
Yes
No
If yes, please describe:
LOSS HISTORY
Date
Description of Incident
Amount Paid / Reserved
$
$
$
$
1.
Do you have knowledge of any incident which may lead to a claim?
Yes
No
If yes, please describe:
Years
Years
Retail Archery and Range Application
Page 4 of 5
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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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 T
O 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)
Retail Archery and Range Application
Page 5 of 5
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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RETAIL ARCHERY AND RANGE APPLICATION (Philadelphia Insurance Companies)

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