Fillable RV PARK & CAMPGROUND APPLICATION (Philadelphia Insurance Companies)

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RV PARK & CAMPGROUND APPLICATION (Philadelphia Insurance Companies)

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RV PARK & CAMPGROUND APPLICATION
SUBMISSION REQUIREMENTS
• All brochures describing any and all services; or website address.
• 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.).
• Pet Rules, Park Rules or Membership Agreements.
• Documentation that the Applicant’s LP fill station meets code, if applicable
GENERAL INFORMATION
Named Insured:
Principal Contact:
Mailing Street Address:
Mailing City: State: Zip:
Location Street Address:
Location City: County: State: Zip:
Phone Number: Fax Number:
Website: www.
Risk Management Contact:
Risk Management’s Phone Number: Risk Management’s Email:
Business Form: Corporation Partnership Individual LLC Other:
Effective Date:
Limit of Liability Requested: $ 300,000 Occurrence
$ 500,000 Occurrence
$ 1,000,000 Occurrence
1. Does the Applicant 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 other business:
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:
TELEPHONE E-MAIL:
THIS IS AN APPLICATION FOR INSURANCE. THIS IS NOT A BINDER OF INSURANCE.
• Special Events application in fireworks, concerts, fairs or other similar activities take place
RV Park and Campground
Page 1 of 10
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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PROPERTY SECTION
Premises Information
Building Information
1. Are there smoke alarms in all corridors and bedrooms? Yes No
2. What types of smoke alarms are installed? Battery Hardwired
3. Is there a CO alarm installed? Yes No
4. Do any buildings have cooking facilities? Yes No
If yes, list building numbers:
5. Do any buildings have wood burning fireplaces and/ or woodstoves? Yes No
If yes, list building numbers:
If yes, are the chimneys and flues cleaned annually? Yes No
6. Do any buildings have any ACTIVE Knob & Tube and/ or Aluminum wiring? Yes No
If yes, list building numbers:
DOCK INFORMATION
1. Number of docks:
2. Number of boat slips:
Complete the questions below only if property coverage is requested.
3. Construction: Frame Metal Floating Fixed Roofed Age:
If roofed, has proper engineering for wind/ snow loads been assessed? Yes No
4. Does the water around the Applicant’s dock freeze? Yes No
If yes, what date on average:
5. Are the docks removed? Yes No
ACCOUNT INFORMATION
Management Information
1. How long has the Applicant owned this park? Years
2. Does the Applicant or the Applicant’s manager live on premises? Yes No
3. Does the Applicant have a dog(s)? Yes No
If yes, what breed(s)?
If yes, is the Applicant’s pet ever allowed into guest areas or around guests? Yes No
4. Does the Applicant have a guest dog breed restriction policy in place? Yes No
5. Does the park have security patrol? Yes No
If yes, is the security patrol armed? Yes No
6. Is the park fenced or gated? Yes No
7. Is there a formal maintenance program for the grounds and landscaping? Yes No
1. Distance to fire station? Miles
2. Is the responding fire department: staffed or volunteer
3. Distance to fire hydrant? Feet
4. Are there other fire control water sources available?
Pool Pond/ Lake Water Tank Other:
5. Are there buildings at the Applicant’s facility with limited access due to forest
terrain or season? Yes No
6. Are the Applicant’s buildings located in heavily wooded areas? Yes No
7. Is the clearing from forest/ wooded areas greater than 150 feet? Yes No
8. Is the Applicant’s business operational year round? Yes No
9. If no, provide the number of months the Applicant is operational: Months
10. Are the Applicant’s buildings occupied year round? Yes No
11. If no, is there a caretaker on site? Yes No or contracted? Yes No
12. If no, are buildings winterized? Yes No
RV Park and Campground
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02/2019
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8.
Is the electrical installation and maintenance done by a licensed electrician?
Yes
No
9.
Does the park/ resort service or repair engines (RV, Marine, Auto)?
Yes
No
10.
Does the Applicant sell beer/ wine/ liquor?
Yes
No
11.
Is there a bar/ lounge on the premises?
Yes
No
If yes, is it open to the general/ non-camping public?
Yes
No
12.
Is the Applicant’s park a member of any state or regional association or
franchise?
Yes
No
If yes, please list:
13.
Does the Applicant have, or has the Applicant ever had fuel storage on-site?
Yes
No
If yes:
a.
Specify the type of fuel:
b.
What is the containment method (cans, tanks, drums etc.):
c.
What is the maximum volume at any one time:
14.
Does the Applicant have or has the Applicant ever had a dumping station?
Yes
No
If yes:
a.
What are the acceptable classes of waste?
b.
How is the waste contained?
c.
What are the Applicant’s disposal practices?
15.
Does the Applicant have or has the Applicant ever had On-Site Pump Out
available?
Yes
No
If yes:
a.
Please specify the containment method of waste:
b.
How does the Applicant dispose of the waste?
16.
Has the Applicant, in the past 5 years, had a release of waste or pollutants of any
sort that resulted in clean-up that was mandated or over-seen by federal, state or
local authorities, or claims for Bodily Injury or Property Damage?
Yes
No
If yes, please provide details.
PARK INFORMATION
# of Units
Type of Guest Unit
Type of Clientele, check and give percent of each:
RV Pads
Residential (annual)
Seasonal (monthly)
Vacation (weekly/daily)
%
Tent Sites
%
Single Cabins
%
Duplex Cabins
Park Model/ Modulars
Lodge Units
Other:
1.
Does the Applicant require guests and/ or visitors to sign an acknowledgement of
risk or liability waiver?
Yes
No
RV Park and Campground
Page 3 of 10
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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ACTIVITY SECTION
Actual Total Receipts for Prior 12 Months:
$
Estimated Total Receipts for Next 12 Months:
$
Activities Conducted
Number of Units
Revenues
General Store
$
Restaurant
What % of sales from non-camping guests?
$
%
Snack Bar
$
Liquor
$
LP Gas
$
Gasoline
$
Laundry
$
Gun/ Archery Range
$
Horseback Riding
$
Hay, Sleigh or Wagon Rides
$
Bicycle Rentals
$
Tennis/ Basketball Court
$
Athletic Fields
$
Playground
$
Canoes
$
Float Tubes
$
Go-karts
$
Golf Carts
$
Miniature Golf
$
RV or Travel Trailer Storage
$
RV or Travel Trailer Sales & Service
$
Special Events: weddings, reunions, etc.
$
Petting Zoo
Is petting zoo area fenced off from guests?
Yes No
$
Trails for guest owned ATV touring
Are trails on the Applicant’s premise?
Yes No
$
Trampolines or Jump Houses
$
Jumping Pillow
$
Water Skiing
$
Waverunners and Jet Skis
$
Hobby Shops or Classes, explain:
$
1.
What recreational and sporting activities, other than those listed above, are conducted or take place
at the Applicant’s park/ resort?
2.
Is the Applicant’s premise open to the general public for day use other than
camping?
Yes
No
If yes, for what type of activities?
3.
What are the revenues from these activities?
4.
Does the Applicant’s park have a jumping pillow (or Kangaroo Jumper or similar
amusement device)?
Yes
No
If yes, please answer the below questions:
a.
Are all participants required to sign a waiver? Please provide copy for review.
Yes
No
b.
Is there a roll off area of Pea Gravel or sand maintained around the entire
periphery of the jumper at least 4” above the pillows edge?
Yes
No
c.
Are all participants’ pockets empty and removal of all cell phones enforced
before jumping?
Yes
No
d.
Does the jumping pillow have anti-slip surface?
Yes
No
RV Park and Campground
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e.
Is the Applicant’s jumping pillow monitored by a staff member (within 50 feet)
at all times it is open?
Yes
No
f.
Is the Applicant’s jumping pillow fenced with a locked gate when it is not in
use?
Yes
No
g.
Does the Applicant have a variable speed air pump for the Applicant’s jumping
pillow?
Yes
No
If yes, does the Applicant utilize it to control the height at which guests can
jump?
Yes
No
h.
Is the Applicant’s jumping pillow deflated when not in use?
Yes
No
i.
Does the Applicant have written procedures in place to advise the Applicant’s
staff on how to control the size and number of jumpers on the pillow?
Yes
No
If yes, please send those procedures with the submission.
POOL AND SWIMMING AREAS N/A
1. How many of each: Pools: Lakes: Other:
Are all swimming pools and spas compliant with Virginia Graeme Baker Pool and
Spa Safety Act? If no, provide time table and action plan:
Yes No
2. Are the Applicant’s swimming facilities open to the general public? Yes No
3. Fenced? Yes No
4. Diving Board? Yes No
5. Locking Gate? Yes No
6. Is the depth of pool marked? Yes No
7. Are life rings or buoys provided? Yes No
8. Life Guard on Duty? Yes No
9. Pool Rules posted? Yes No
10. Is there signage “No life guard, swim at your own risk, no diving”? Yes No
11. Is a trained employee available for emergencies? Yes No
12. Does the Applicant have a waterslide? Yes No
If yes, what is the length & height of slide? Length /Height
WATERCRAFT LIABILITY SECTION N/A
Boat Schedule if necessary use another sheet of paper
Year Make & Model Length HP OB/IB/IO # Pass Guided
Yes No
Yes No
Yes No
Yes No
WATERCRAFT GENERAL INFORMATION
1. What type of operation does the Applicant have?
Boat Rentals Fishing Trips Tube or Canoe Rentals Hunting Other:
2. On what bodies of water does use take place?
Rivers Lakes Ocean Bays/ Inlet
3. If Rivers, what classes are boated:
Class I Class II Class III Class IV Class V
4. Are life vests (PFD’s) required? Yes No
5. Are life vests (PFD’s) provided? Yes No
CANOE, KAYAK, AND/ OR RIVER TUBING INFORMATION N/A
Boat Type Maximum Number Used Average Number Used
Canoes
Kayaks
Tubes
1. Number of guides:
2. What percent of the Applicant’s operations are unguided? %
RV Park and Campground
Page 5 of 10
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
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AUTOMOBILE
1. Does the Applicant have a formal driving policy in place with MVR standards? Yes No
If yes:
a. Is driving policy communicated in writing to all employees? Yes No
b. Is a signed acknowledgement form kept on file? Yes No
If yes, please provide a copy of signed acknowledgement.
c. Do driving standards include the following:
i. No major violations including DUI, racing, hit and run, speeding in
excess of 20 mph over posted speed limit, manslaughter?
Yes No
ii. No more than 2 moving violations within past 3 years? Yes No
iii. No more than 1 at fault accident within past 3 years? Yes No
2. How often does the Applicant check MVR reports?
3. Does the Applicant allow any newly hired drivers to operate vehicles without
going through a company-specific documented driver training?
Yes No
4. Describe any ongoing training provided to drivers:
5. Does the Applicant have GPS tracking capability? Yes No
6. Does the Applicant allow employees to drive personal vehicles for company
purposes?
Yes No
If yes:
a. Are the driving policy and standards for these drivers the same as in
questions 1-3?
Yes No
b. Does the Applicant require these employees to have adequate personal
insurance limits?
Yes No
LOSS HISTORY
Date Description of Incident Amount Paid/Reserved
$
$
$
$
1. Yes NoDoes the Applicant have knowledge of any incident which may lead to a claim?
If yes, please describe:
RV Park and Campground
Page 6 of 10
© 2019 Philadelphia Consolidated Holding Corp.
02/2019
LP GAS DISTRIBUTION – FILL STATION N/A
1. Does the Applicant have documentation that LP Fill Station meets all state and
Local LP codes for training, equipment etc.? Yes No
2. Are employees certified and trained to fill LP gas tanks? Yes No
3. Is fill station fenced or secured? Yes No
4. How many fixed LP gas tanks does the Applicant have on premise?
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WINTER WEATHER FREEZE-UP PROTECTION
1. Fire Protection and Testing
a. Is the building provided with an Automatic Fire Sprinkler System (AS)? Yes No N/A
i. If yes, approximately what percentage (%) of the building is sprinklered? %
ii. If yes, what type of sprinkler system is installed? Wet-Pipe Dry-Pipe Both
iii. If yes, when possible, is the sprinkler piping primarily run within conditioned
areas designed to ensure the temperature remains above the 45°F minimum
Yes No N/A
iv. If yes, is the testing & inspection by qualified sprinkler contractor completed
within past 12 months & includes a formal winterization re
view?
Yes
No
N/A
v. If yes, are the alarms tied to a 24 hour UL listed monitoring company?
Yes
No
N/A
2. Emergency Water Response (domestic and AS water lines)
a. Are water shutoff valves (domestic and AS water lines) marked and readily
accessible?
Yes
No
N/A
b. Are water shutoff valves exercised (closed and reopened) at least annually?
Yes
No
N/A
c. Is the staff qualified to respond and shut off the water main during normal business
hours and off hours?
Yes
No
N/A
3. Automatic Water Shutoff Devices
a. For domestic water lines, is there a water flow detection, notification and automatic
shutoff?
Yes
No
N/A
4. Unused/Vacant Spaces
a. Does Applicant have a formal process to turn off and drain domestic water lines for
these spaces?
Yes
No
N/A
5. Unheated Areas (attics, crawl spaces, exterior wall joists)
a. Are all domestic water lines located in areas heated to at least 45°F?
Yes
No
N/A
i. If no, please describe freeze prevention measures (e.g. temperature monitoring,
heat trace, full insulation):
This section must be completed by all risks that have a location in one of the following states: AR, CT, DC, DE,
GA, IL, IN, KY, ME, MD, MA, MI, MO, NH, NY, NJ, NC, OH, PA, RI, SC, TN, TX, VT, VA, WV, WI
temperature?
1. If no, please describe freeze prevention measures (
e.g. temperature
monitor
ing, heat trace, full insulation on piping or roof):
6.
General Comments:
RV Park and Campground
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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 F ALSE 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 ST ATEMENT 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)
RV Park and Campground
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.
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 th
e Applicant alleging i
nvasion 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)
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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 ST ATEMENT 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)
PI-CYBE-APP (11/16)
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RV PARK & CAMPGROUND APPLICATION (Philadelphia Insurance Companies)

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Completed 29 July 2020

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