Fillable SNOWMOBILE TOUR APPLICATION (Philadelphia Insurance Companies)

Fill Online, Printable, Fillable, Blank SNOWMOBILE TOUR 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.

SNOWMOBILE TOUR APPLICATION (Philadelphia Insurance Companies)

On average this form takes 43 minutes to complete

The SNOWMOBILE TOUR APPLICATION (Philadelphia Insurance Companies) form is 4 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 170 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
 
SNOWMOBILE TOUR APPLICATION
SUBMISSION REQUIREMENTS
•
All brochures describing any and all services; or website address
•
The liability waiver/hold harmless agreement the Applicant requires its guests to sign
•
Three (3) years hard copy Loss Runs.
GENERAL INFORMATION
Business Form: Corporation Partnership Individual LLC Other:
FEIN or SSN:
Limit of Liability Requested:
$300,000 / $300,000 $300,000 / $600,000 $500,000 / $500,000
$500,000 / $1,000,000 $1,000,000 / $1,000,000 $1,000,000 / $2,000,000
OPERATIONS INFORMATION
1. Number of years in business:
2. What is the total number of snowmobile machines available:
3. Of these machines, please note the following:
a. What is the highest cc machine available for guided tours: cc
b. What is the highest cc machine available for unguided guest rental: cc
4. What percent of the Applicant’s operations are guided: % Unguided: %
If any are unguided, are they only allowed to operate on groomed and maintained trails? Yes No
5. Does the Applicant enforce a buddy system when renting snowmobiles to an individual? Yes No
6. What is the maximum guide to guest ratio that the Applicant will allow on a tour:
Number of Guides to Number of Guests
7. Does the Applicant operate any other type of business or any other type of outfitting/guiding
operations during the winter season, or any other season?
Yes No
If yes, please describe:
8. Does the Applicant sell snowmobiles? Yes No
9. Does the Applicant repair snowmobiles for others? Yes No
10. Does the Applicant rent any machinery or equipment other than snowmobiles? Yes No
If yes, please describe:
Fax Number:
Website: www.
Risk Management’s Phone:
Applicant:
Principal Contact:
Mailing Address:
Location Address (important):
Location County:
Phone Number:
Effective Date:
Risk Management Contact:
Risk Management Email:
Snowmobile Tour Application
Page 1 of 4
© 2019 Philadelphia Consolidated Holding Corp.
01/2019
Print Application
Clear Application
INFORMATION
1.
Years
2.
Years
3.
Does the Applicant require participants to sign a snowmobile risk warning or liability release
agreement?
Yes
No
4.
Does the Applicant require helmets for all participants?
Yes
No
5.
Is alcohol consumption by guests prohibited before or while on tour?
Yes
No
6. Does the Applicant require guests to complete a health or physical fitness information form
prior to riding?
Yes
No
7.
Does the Applicant pre-screen guest riders and determine ability prior to riding?
Yes
No
8.
Does the Applicant require participants to sign a waiver or liability release agreement?
Yes
No
9.
Does the Applicant require renters to provide names of Homeowners, Renters or Condo
insurance carriers?
Yes
No
10.
Does the Applicant require a first aid kit to be carried with each sled?
Yes
No
11. Does the Applicant conduct a pre-ride safety briefing with guests or provide instructions on
proper operations?
Yes
No
12.
Does the Applicant have a written pre-ride briefing or safety checklist?
If yes, please provide a copy.
GUIDE INFORMATION
Name Age
Years
Experience
First Aid Qualifications
1.
Do guides carry with them any type of communication device (2-way radio, cell phone, etc.)?
Yes
No
2.
List reasons the Applicant would decline a person from riding a snowmobile (health, age,
weight, alcohol, pregnancy, general):
3.
Does the Applicant have a written safety manual of procedures used by all staff members?
Yes
No
If yes, please provide a copy.
Snowmobile Tour Application
Page 2 of 4
© 2019 Philadelphia Consolidated Holding Corp.
01/2019
Print Application
Clear Application
EQUIPMENT INFORMATION
Number Year Make and Model CC
Attach additional sheet if needed.
PRIOR YEAR’S ANNUAL RECEIPTS:
Annual Receipts
from
Guided Tours
Annual Receipts
from Rental
of Machines
Annual Receipts
from Sales of
Machines
Annual Receipts
from Service of
Machines
Other: Food,
Transportation,
Clothing Rental
$
$
$
$
$
ESTIMATED ANNUAL RECEIPTS FOR NEXT 12 MONTHS:
Annual Receipts
from
Guided Tours
Annual Receipts
from Rental
of Machines
Annual Receipts
from Sales of
Machines
Annual Receipts
from Service of
Machines
Other: Food,
Transportation,
Clothing Rental
$
$
$
$
$
PRIOR CARRIER INFORMATION
Insurance Carrier
Limits of Liability
Premium
Last Year
$
Two Years Ago
$
Three Years Ago
$
LOSS HISTORY
Date
Description of Incident
Amount Paid/Reserved
$
$
$
1.
Does the Applicant have knowledge of any incident which may lead to a claim?
Yes
No
ADDITIONAL INSUREDS (If necessary, use another sheet of paper.)
Name
Complete Address
Interest
1.
Is Waiver of Subrogation needed?
Yes
No
If yes, please provide a schedule of entities requiring this coverage.
Snowmobile Tour Application
Page 3 of 4
© 2019 Philadelphia Consolidated Holding Corp.
01/2019
Print Application
Clear 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 B
E 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)
Snowmobile Tour Application
Page 4 of 4
© 2019 Philadelphia Consolidated Holding Corp.
01/2019
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

SNOWMOBILE TOUR 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