Fillable Supplemental- Fuel Dealers36-9894

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Supplemental- Fuel Dealers36-9894

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FUEL DEALER SUPPLEMENTAL APPLICATION
Applicant:
Address:
Owner and/or Manager responsible for daily operations:
Website: FEIN:
Date established: Proposed policy effective date:
Business type: Sole Proprietor C-Corporation S-Corporation Partnership
Current Carrier Line of Coverage Current Premiums
Business Operations (check all that apply)
Auto Service & Repair Convenience Stores HVAC Installation or Repair
Bulk Oil Sales Fuel Distributor/Dealer LP Bulk Storage
Bulk Storage (gas, diesel) Home Heating Fuel Propane Distributor
Common Carrier Other:
1. Any other entities, subsidiaries, joint ventures or partnerships associated with applicant? Yes
No
2. What is the name and title of individual responsible for safety program?
How many years of experience in this role?
Contact information:
SECTION I – FUEL DEALER GENERAL INFORMATION
1.
How many years has current management been in place?
2.
Has there been a merger or acquisition with another business entity within the past 3 years?
Yes
No
3.
Does the Applicant have formal hiring practices to include:
a.
Yes
No
b.
Yes
No
c.
Yes
No
4.
Does the Applicant business include any of the following:
a.
Yes
No
b.
Yes
No
d.
Yes
No
e.
Yes
No
f.
Yes
No
g.
Yes
No
h.
Yes
No
i.
Yes
No
j.
Yes
No
k.
Yes
No
I.
Do HVAC service/repair receipts exceed 20% of applicant’s total annual sales?
Yes
No
II.
Do HVAC new installations exceed 10% of total HVAC receipts?
Yes
No
III.
Any HVAC installations involving rooftop crane operations?
Yes
No
l.
Yes
No
5.
Does the Applicant hire subcontractors to perform any work?
Yes
No
If yes:
a.
Yes
No
b.
Yes
No
c.
Any sale of racing fuel?
Yes
No
If Yes: %
US DOT #:
Fuel Dealers Application
Page 1 of 9
© 2018 Philadelphia Consolidated Holding Corp.
10/2018
Print Application
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SECTION II - AUTO
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
c. Do driving standards include the following: Yes No
•
No major violations including DUI, racing, hit and run, speeding in excess of 20 mph over
posted speed limit, manslaughter?
•
No more than 2 moving violations within past 3 years?
•
No youthful transport truck drivers (under age 25)?
•
No more than 1 at fault accident within past 3 years?
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. Has the Applicant incurred any instances of bulk transport vehicle theft or other unauthorized use of
their bulk transport vehicles?
Yes No
5. How many drivers does the Applicant currently have?
6. How manyGULYHUV under age 25?
7. Any drivers with less than 2 years experience? Yes No
8. Describe ongoing training provided to drivers of large trucks and transports:
9. Any personal use of company owned vehicles? Yes No
If yes, on a separate paper please provide list of employees and family members who have access to
company owned vehicles for personal use.
10. Any use of speed regulators on heavy trucks? Yes No
11. Does the Applicant have GPS tracking capability on heavy trucks and transports? Yes No
12. Does the Applicant haul any products other than fuel (gasoline, diesel, kerosene,bio diesel, ethanol,
etc.), bulk oil, or propane? Yes No
13. Does the Applicant’s operations include “slip seating” beyond two shifts or operate between the hours
of 1:00 A.M. and 5:00 A.M.?
Yes No
14. What is the farthest distance traveled by any one delivery unit?
15. What is the average distance traveled by any one delivery unit?
16. Daily driving hours are limited to no more than hours per delivery vehicle.
17.
Does the Applicant act as a common or contract carrier and haul fuel for others (the fuel isn’t owned
by them) utilizing their own trucks?
If yes, what is the % of hauling for others? %
Yes No
18.
Does the Applicant use common carriers (3
rd
parties hauling for our Applicant utilizing the 3
rd
parties
trucks)? Yes No
a. If yes, what % of total delivery is performed by common carrier? %
b. Does the Applicant verify that common carrier has liability limits equal to those they carry? Yes No
c. Is the Applicant listed as additional insured on common carrier’s policy? Yes No
1.
Are all bulk plants protected by perimeter fencing?
Yes
No
2.
Outdoor lighting after business hours?
Yes
No
3.
Premises monitored by video surveillance?
Yes
No
4.
Does loading rack have spill containment system in place?
Yes
No
5.
Static bonding cable used?
Yes
No
6.
Are all above ground storage tanks protected by spill containment dikes?
Yes
No
7.
Are all warehouses protected by fire alarm?
Yes
No
Sprinkler System?
Yes
No
8.
Smoking restricted to designated area away from warehouses, loading racks?
Yes
No
9.
Does the Applicant permit any third parties to pull product from any of its bulk storage facilities?
Yes
No
10.
Any location with any one tank greater than 50,000 storage capacity?
Yes
No
11.
Any location with any one LP storage tank greater than 30,000 storage capacity?
Yes
No
12.
Any location with more than 180,000 total LP storage capacity?
Yes
No
13.
Any location where fuel is received or shipped via railcar?
Yes
No
19.
How are the Applicant’s bulk delivery drivers paid:
Hourly
Per Trip
Salary
SECTION III – BULK PLANT PHYSICAL AND OPERATIONAL CHARACTERISTICS
20.
What is the Applicant’s annual Driver turnover percentage? %
(# of new drivers in the past 12 months divided by the total # of drivers)
*COPY OF FORMAL DRIVING POLICY MUST BE SUBMITTED WITH SUPPLEMENTAL*
Fuel Dealers Application
Page 2 of 9
© 2018 Philadelphia Consolidated Holding Corp.
10/2018
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SECTION IV – PROPANE GAS (LIQUEFIED PETROLEUM GAS) OPERATIONS
Complete this section only if LPG operations apply.
*COPY OF CONSUMER INSTALLATION FORM MUST BE SUBMITTED WITH SUPPLEMENTAL*
1. Does every employee (including office staff) that is engaged in the sale, transport, or delivery of
propane gas and/or related appurtenances complete the principles and practices module of the
certified employee training program (CETP) or an equivalent program administered by a third party
vendor? If not CETP, name of alternative program and vendor
Yes No
2. Does the Applicant maintain an individual customer file for all propane clients served (electronic
and/or hardcopy)?
Yes No
3. Does the Applicant have a documented system leak check and specific appliances on the system on
at least 50% of their customer base?
Yes No
4. Does the Applicant’s propane customer record keeping form document the leak check, appliances on
the system, venting of the appliances, and the presence of any unused gas piping outlets?
Yes No
5. Does the Applicant provide and document the provision of every new propane customer receiving
consumer product safety information, including a scratch and sniff sample (duty to warn)? The duty to
warn information is also provided at least annually to all regular customers.
Yes No
6. Does the applicant provide formal training in handling propane emergencies to all individuals,
including after-hours answering services, who could receive a phone call from a customer reporting a
gas leak or other emergency?
Yes No
7. Is a documented leak check performed in all of the following situations:
a. Immediately after filling an “out of gas” customer? NOTE: The use of valve locks or line plug(s)
are acceptable alternatives until a pressure test can be performed.
Yes No
b. After any service work is performed where the system has been depressurized? Yes No
c. Immediately after new gas piping is installed? Yes No
d. As part of the dealer’s investigation of a suspected gas leak? Yes No
e. When the dealer performs a consumer installation inspection for a prospective customer, new
customer, or a change in tenants at rental occupancy?
Yes No
8. Does the Applicant keep a record (including serial number) of all owned propane storage tanks? Yes No
9. Does the Applicant have a documented regulator replacement program (at manufacturer’s
recommended service intervals)?
Yes No
10. Does the Applicant have a written record of all training provided to customers who perform liquid
transfer of propane gas?
Yes No
11. Does the Applicant fill any cylinders directly from the bobtail? Yes No
Type and Number of cylinders filled: #
12. Does the Applicant engage in the sale of non-odorized LP gas? Yes No
13. Does the Applicant agree to decline purchase of a customer list/base whereby at least 50% of the
installations assumed do not have a documented leak check and appliances on the system?
Yes No
14. Does the Applicant service any multi-customer installations?
Yes No
If yes, do any installations have 10 or more customers served by the system? Yes No
16. Does the Applicant engage in any motor fuel conversions? Yes No
17. Does the Applicant provide recertification of any tanks? Yes No
If yes, number of tanks per year: #
18. Does the applicant refurbish/repair any tanks? Yes No
If yes, please describe extent of operation:
19.
Does the Applicant use a 3
rd
party vendor or subcontractor to refurbish any tanks, including tanks
owned by the Applicant?
Yes
No
If yes:
a.
Yes
No
b.
Yes
No
15. Does the Applicant have more than 20% of the customer base comprised of customers that are in
rented occupancies?
Yes
No
20.
Does the Applicant fill 20 lb. cylinders?
Yes
No
If yes, how many are filled annually?
Annual gallons?
Fuel Dealers Application
Page 3 of 9
© 2018 Philadelphia Consolidated Holding Corp.
10/2018
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SECTION V – HOME HEATING OIL DELIVERY
Complete this section only if Home Heating Oil Delivery operations apply.
1.
Has the Applicant incurred any at-fault spill claims in the past 5 years?
Yes
No
2.
Does the Applicant inspect indoor / basement tanks before filling for the first time?
Yes
No
3.
Number of customers with indoor / basement tanks: #
4.
Does the Applicant tag the point of fill with a unique identifying mark for all indoor oil storage tanks?
Yes
No
5.
Does the Applicant fill any indoor storage tanks that are not equipped with a fill pipe and vent pipe
terminating outside of the building?
Yes
No
6.
What percent of the Applicant’s home heating oil customer base are:
Will call: %
vs.
Automatics: %
7.
What percent of the Applicant’s home heating oil customer base are Full service accounts? %
8.
Do written contracts contain Hold Harmless clauses due to the condition of the tank?
Yes
No
9.
Does the Applicant have an oil mis-delivery prevention program? (If yes, please send a copy)
Yes
No
10.
Does the Applicant have a strict “no whistle, no fill” policy?
Yes
No
SECTION VI – CONVENIENCE STORE PHYSICAL AND OPERATIONAL CHARACTERISTICS
Complete this section only if Convenience Store Operations apply.
1.
How many convenience stores does the Applicant operate?
a.
b. How many owned or operated convenient stores where customer restrooms are located outside
2.
Any convenience store with on-site alcohol consumption?
Yes
No
3.
Any firearm sales?
Yes
No
4.
Any sales of hard liquor?
Yes
No
5.
Any video gaming?
Yes
No
6.
Any “payday loan” operations?
Yes
No
7.
Any tanning bed operations operated by the Applicant?
Yes
No
If yes, # of beds: #
Amount of receipts: $
8.
Any locations (or portion of a location) of Applicant’s premises is leased to 3rd party?
Yes
No
If yes:
a.
Is there a written contract?
Yes
No
b.
Yes
No
c.
Yes
No
9.
Do ALL convenience stores with commercial cooking operations (flat grills and/or deep fat frying)
meet ALL of the following criteria:
N/A
a.
Yes
No
b. The inside of the exhaust hood and ductwork is cleaned at regular service intervals by a
Yes
No
c.
Yes
No
d.
Yes
No
10. Are ALL stores that permit unattended self-service motor fueling by members of the general public
(excluding commercial accounts) equipped with the following as required by NFPA 30A:
N/A
a.
Yes
No
b.
Yes
No
c.
Yes
No
d.
Yes
No
e. A telephone provided on the premises that is accessible to customers during the unattended
Yes
No
11.
Do ALL convenience stores that fill LP gas cylinders meet the following:
N/A
a.
Yes
No
b.
with a lock OR a tank valve lock AND a locked dispensing cabinet?
Yes
No
c.
At least one maintained and accessible fire extinguisher?
Yes
No
12.
Describe C-Store security measures:
Fuel Dealers Application
Page 4 of 9
© 2018 Philadelphia Consolidated Holding Corp.
10/2018
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Drop safe used?
Yes
No
Any locations with bullet-proof protective glass for attendant safety?
Yes
No
How many C-Store employees are there?
Annual turnover %: %
How many C-Store managers?
Annual turnover %: %
Any bonus or incentive for C-Store managers based on safety/loss results?
Yes
No
If yes, please explain:
Any formal training for C-Store employees? (check all that apply)
Alcoholic Beverage Sales
Prevention of Slips, Trips, Falls
Anti-Discrimination / Harassment
Safe Robbery Response Protocol
Does employee acknowledge training session with signature?
Yes
No
*Please provide sample forms used for documentation.
Any prior safety concerns recognized and addressed by management?
Yes
No
If yes, please explain:
Does the Applicant own or operate a car wash?
Yes
No
If yes, how many?
SECTION VII – LIQUOR LIABILITY
Complete this section only if Liquor Liability coverage is desired.
1.
Total number of locations selling alcohol:
2.
In what states do you sell alcohol?
3.
Total annual sales from beer and wine?
$
4.
Total annual sales from hard liquor?
$
5.
Are there liquor sales for onsite consumption?
Yes
No
If yes, please explain:
6.
Limits desired:
$500,000 Aggregate
$500,000 Each Common Cause
$1,000,000 Aggregate
$1,000,000 Each Common Cause
7.
Within the past 5 years, has the insured been cited by the Liquor Control Commission or for violation
of beverage laws?
Yes
No
If yes, please explain:
8.
Within the past 5 years, has the Applicant had any insurance carrier cancel, non-renew or refuse
coverage?
Yes
No
If yes, please explain:
SECTION VIII – EMPLOYMENT PRACTICE LIABILITY
N/A
(Complete this section only if EPLI, coverage is desired.)
THIS SECTION IS AN APPLICATION FOR A CLAIMS MADE POLICY. PLEASE READ YOUR POLICY CAREFULLY.
1.
Employees
Total US based employees
Currently
One Year Ago
Total Full Time:
Total Part Time:
2.
How many employees have been terminated in the past 12 months?
Voluntary:
Involuntary:
Laid Off:
3.
Is any reduction of employees or change of status anticipated or being contemplated in the next year?
Yes
No
If yes, number estimated:
Voluntary:
Involuntary
Laid Off:
13.
14.
15.
16.
17.
18.
19.
20.
Fuel Dealers Application
Page 5 of 9
© 2018 Philadelphia Consolidated Holding Corp.
10/2018
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4.
Human Resource Policies and Procedures:
Does the Applicant utilize:
a.
Yes
No
b.
Yes
No
c.
Yes
No
d.
Yes
No
e.
Yes
No
f.
Yes
No
5.
Third Party Policies and Procedures:
Does the Applicant:
a.
vendors, the general public or other third parties, including non-discrimination and non-
Yes
No
b. Have policies or procedures for responding to complaints of harassment, discrimination, or civil
Yes
No
6.
Current EPLI Coverage (if none, do not complete this section)
Employment
Practices
Coverage
Insurance Company Limit of Liability Deductible Effective Date Premium
Currently
$
$
$
Prior Year
$
$
$
Retroactive date on current policy:
SECTION IX – CLAIM/WARRANTY SECTION
1.
With respect to the coverage addressed in this application, has any Underwriter refused, canceled, or
non-renewed coverage? (Not applicable in Missouri)
Yes
No
2. With respect to the coverage addressed in this Application, has the Underwriter indicated any intent to
not offer renewal terms to the Applicant? (Not applicable in Missouri)
Yes
No
3.
Has the Applicant given written notice under the provisions of any prior policies providing similar
insurance of claims, or of specific facts or circumstances which might give rise to a Claim being made
against any person or entity applying for this insurance?
Yes
No
4.
No person applying for Employment Practice Liability (EPL) coverage is aware of any facts or
circumstances that may give rise to a Claim under this coverage. None, or as noted below:
(provide attachment if necessary)
SECTION X – CYBER SECURITY LIABILITY
Complete this section only if Cyber Security Liability coverage is desired. *Indication quote only*
1.
Gross Annual Sales: $
2.
Gross Annual Sales less Fuel Costs: $
3.
During the past three (3) years whether insured or not, has the Applicant sustained any Losses due
to unauthorized access, unauthorized use, virus, denial of service attack, electronic media
liability,data breach, data theft, fraud, electronic vandalism, sabotage or other similar electronic
security events?
Yes
No
4.
During the past three (3) years, has anyone made a demand, claim, complaint, or filed a lawsuit
against the Applicant alleging invasion of interference of rights of privacy or the inappropriate
disclosure of
Personally Identifiable Information (PII)?
Yes
No
5.
During the past 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
6.
Is the Applicant in compliance with PCIDSS (Payment Card Industry Data Security Standard).
Yes
No
7.
Does the Applicant’s hiring process include the following for all employees and independent
contractors (check all that apply):
Drug Testing
Educational background
Credit history checks
Criminal background checks
Work history checks
Other (specify):
8.
Are all employees periodically instructed on their specific job responsibilities with respect to
information security, such as the proper reporting of suspected security incidents?
Yes
No
Fuel Dealers Application
Page 6 of 9
© 2018 Philadelphia Consolidated Holding Corp.
10/2018
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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, 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 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)
Fuel Dealers Application
Page 7 of 9
© 2018 Philadelphia Consolidated Holding Corp.
10/2018
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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
the Applicant alleg
ing invasion 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
Fuel Dealers Application
Page 8 of 9
© 2018 Philadelphia Consolidated Holding Corp.
10/2018
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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
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KN
OWINGLY 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, 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 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 (PL
EASE 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 AGE
NCY
(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)
Fuel Dealers Application
Page 9 of 9
© 2018 Philadelphia Consolidated Holding Corp.
10/2018
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Completed 2 July 2020

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