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SWIMMING POOL MAINTENANCE AND MANAGEMENT SUPPLEMENTAL APPLICATION (Colonial General Insurance Agency, Inc)

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GLS-APP-51s (9-16) Page 1 of 5
Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
SWIMMING POOL MAINTENANCE AND MANAGEMENT SUPPLEMENTAL APPLICATION
(Complete in addition to the ACORD General Liability Application)
Applicant’s Name:
Location Address:
Agency Name:
Agent No.:
Phone No.:
E-mail:
PROPOSED EFFECTIVE DATE: From: To: 12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
A. GENERAL INFORMATION:
1. Does risk engage in the generation of power, other than emergency back-up power, for their
own use or sale to power companies? .............................................................................................
Yes No
If yes, describe:
2. Does applicant have any other business ventures for which coverage is not requested? ........ Yes No
If yes, explain and advise where insured:
B. POOL MAINTENANCE OPERATIONS:
Employee Data Number Annual Payroll
Owner(s) only
$
Maintenance: Full-time
$
Part-time
$
Leased or Subcontracted Number Annual Cost
Leased employees—maintenance: Full-time
$
Part-time
$
Independent contractors—maintenance: Full-time
$
Part-time
$
GLS-APP-51s (9-16) Page 2 of 5
1. Limited Coverage For Property Damage From Swimming Pool Pop Up limits:
$50,000 each occurrence/$100,000 aggregate (included) Other Limits: Exclude
2. Does applicant rent portable spas? .................................................................................................. Yes No
3. Does applicant manufacture or sell any products under their own label? ................................... Yes No
If yes, complete and submit the Products Liability Application.
4. Any underground tanks, petroleum products, LPG, flammable liquids or explosives stored
on premises? .......................................................................................................................................
Yes No
If yes, type and quantity stored:
5. Any equipment loaned, leased or rented to others? ....................................................................... Yes No
If yes, describe type of equipment and annual rental receipts:
6. Does applicant subcontract work? ................................................................................................... Yes No
If yes, describe type of work:
7. Are certificates of insurance obtained from subcontractors? ....................................................... Yes No
8. Are all operations in compliance with the federal Virginia Graeme Baker Pool and Spa Safe-
ty Act? ..................................................................................................................................................
Yes No
9. Are all chemicals EPA-approved and stored in EPA-approved containers? ................................ Yes No
10. Does applicant offer services other than pool maintenance? ....................................................... Yes No
If yes, explain:
11. Any swimming pool construction, renovation, refurbishing or replastering operations? ......... Yes No
If yes, explain:
12. Any servicing or maintenance for lakes or ponds? ........................................................................ Yes No
If yes, explain:
C. POOL MANAGEMENT OPERATIONS:
Employee Data Number Annual Payroll
Lifeguards Full-time
$
Part-time
$
Instructors Full-time
$
Part-time
$
Leased Employees
Number
Annual Cost
Lifeguards Full-time
$
Part-time
$
Instructors Full-time
$
Part-time
$
GLS-APP-51s (9-16) Page 3 of 5
Independent Contractors Number Annual Cost
Lifeguards Full-time
$
Part-time
$
Instructors Full-time
$
Part-time
$
1. Sexual and/or Physical Abuse Coverage limits:
$25,000 Each Claim/$50,000 Aggregate (included)
$50,000 Each Claim/$100,000 Aggregate
$100,000 Each Claim/$300,000 Aggregate
2. Number of pool services annually: ...................................................................................................
3. Are all lifeguards and instructors American Red Cross certified or equivalent? ........................ Yes No
4. Do lifeguards/instructors teach diving, skin diving or scuba classes? ........................................ Yes No
5. Type of clients serviced:
Condo/HOA Hotels/Motels Lakes/Ponds Municipal pools
Ocean beaches, private Ocean beaches, public Private clubs Private homes
Public beaches Water amusement parks Wave pools
Other (describe):
6. Any clients with wave pools or pools with slides or diving boards/platforms in excess of
ten (10) feet? ........................................................................................................................................
Yes No
7. Are all swimming pools, wading pools, hot tubs and spas in compliance with the federal
Virginia Graeme Baker Pool and Spa Safety Act? ...........................................................................
Yes No
8. Does applicant offer services other than those related to swimming pool management
operations? ..........................................................................................................................................
Yes No
If yes, explain:
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
FRAUD WARNING: 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. (Not applicable in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY,
OH, OK, OR, RI, TN, VA, VT or WA.)
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation 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 policy holder or claimant for
the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
GLS-APP-51s (9-16) Page 4 of 5
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: 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 addi-
tion, an insurer may deny insurance benefits if false information materially related to a claim was provided by the appli-
cant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insur-
er files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a fel-
ony of the third degree.
NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be pre-
sented 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 statement as part of, or in support of, an application for the issuance of, or the rating of an in-
surance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance pol-
icy 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, commits
a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
NOTICE TO LOUISIANA 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 sub-
ject to fines and confinement in prison.
NOTICE TO MAINE 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 may include imprisonment, fines or a denial of
insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he 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 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 infor-
mation is guilty of a felony.
NOTICE TO RHODE ISLAND 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 fines and confinement in prison.
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents
a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties un-
der state law.
FRAUD WARNING (APPLICABLE IN 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. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
GLS-APP-51s (9-16) Page 5 of 5
NEW YORK FRAUD WARNING: 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.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an active owner, partner or executive officer)
PRODUCER’S SIGNATURE: DATE:
PRODUCER’S ADDRESS:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IOWA LICENSED AGENT:
(Applicable in Iowa Only)
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional
information as to the nature and scope of the report, if one is made, will be provided.
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SWIMMING POOL MAINTENANCE AND MANAGEMENT SUPPLEMENTAL APPLICATION (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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