Fillable TEMPORARY STAFFING AGENCY NEW BUSINESS APPLICATION (Combined Commercial (Philadelphia Insurance Companies)

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TEMPORARY STAFFING AGENCY NEW BUSINESS APPLICATION (Combined Commercial (Philadelphia Insurance Companies)

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TEMPORARY STAFFING AGENCY NEW BUSINESS APPLICATION
(Combined Commercial Package / Management & Professional Lines)
Name of Applicant:
Address:
City: State: Zip:
Website: E-Mail:
Date Established: Telephone Number:
SUBMISSION REQUIREMENTS
• Currently valued insurance company loss runs for the current policy period plus three (3) prior years
• ACORD Applications
• Completed signed/dated Temporary Staffing Agency Combined Supplemental Application
• Workers Comp class codes and estimated payroll breakdown
• New Ventures must provide a business plan inclusive of Applicant experience
Whenever used in this Application the term Applicant shall mean the Named Insured / Named Entity / Private
Company and its subsidiaries. Certain coverages addressed in this Application are provided on a Claims Made
and Reported basis, please read your policies carefully. Employee includes permanent and staffed / temporary
placed employees.
SECTION I – GENERAL INFORMATION
1. Please provide a breakdown of the Applicant’s Corporate Employees, Temporary Placements, Recruiting,
PEO/ASO Operations:
Prior Year Actual Next Fiscal Year Projection
Total Number of Full Time Corporate Employees
(In House)
Total Number of Part Time Corporate Employees
(In House)
Total Number of Independent Contractors
(In House)
Corporate Employee Payroll (In House)
Number of Contract/Temporary Placements
Total Payroll of all Contract/Temporary
Placements (do not include leasing payroll) $ $
Number of Worksite Employees (PEO/ASO only)
Worksite Employees Payroll (PEO/ASO only) $ $
Total Gross Receipts (deducting pass through
payroll) $ $
Direct Hire Percentage of Total Revenue % %
Total Percentage of Employees located in CA
(Contract/Temporary/PEO/ASO) % %
2. How many of the Applicant’s Corporate Employees have been terminated or demoted in the
past twelve (12) months? Voluntary: Involuntary: Laid Off:
3. Is any reduction in corporate employees anticipated within the next year? Yes No
Temporary Staffing Agencies
New Business Application
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04/2017
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4. Provide a brea
kdown of the types of staffing services offered to the Applicant’s clients:
Administrative/ Clerical* % Daycare %
Executive % Attorneys %
Computer/IT Services % Construction/Carpentry/Skilled Labor %
Financial/Accounting Professionals % Drivers/Transportation %
Janitorial % Nanny Services %
Light Industrial / Warehouse / Factory % Heavy Industrial %
Security Services (Unarmed) % Security Services (Armed) %
Architects/Engineers without Signoff
Authority %
Architects/Engineers with Signoff
Authority %
Hospitality %
Healthcare (excluding Doctors and
Dentists) %
Teachers/Teacher Aides % Doctors/Dentists %
*The following
placements should be categorized as clerical, not IT or Financial/Accounting Professionals –
accounting clerks, bookkeepers, billing clerks, medical billers/coders, filing, receptionsists, data entry
services.
5. Does the Applicant now, or will the Applicant place their employee(s) in a position which
requires the employee(s) to operate:
a. cranes, bulldozers, or trucks over 4,000 lbs.? Yes No
b. aircraft or watercraft? Yes No
6. Does the Applicant transport temporary staffing employees to job sites? Yes No
If yes, please attach a list of drivers along with respective dates of birth and answer the following.
Does the Applicant perform MVR checks at time of hire for drivers? Yes No
Does the Applicant perform annual MVR checks thereafter? Yes No
7. Does the Applicant specialize in clinical trial placements by recruiting participants or setting
up the trials? Yes No
8. Does the Applicant have a hold harmless agreement in favor of the Applicant with its client
companies regarding liability for employment actions of the client company? Yes No
9. Does the Applicant:
a. have a standard employment application for all job applicants? Yes No
b. have an employment handbook? Yes No
c. document the receipt of the employee handbook by the employee? Yes No
d. have an At Will provision in the employment application? Yes No
e. have a written policy with respect to sexual harassment? Yes No
f. have a written policy with respect to discrimination? Yes No
10. Does the Applicant have a human resource department? Yes No
If no, describe how the function is handled:
11. Does the Applicant conduct a prior employment check on all new hires? Yes No
12. Does the Applicant conduct criminal background checks? Yes No
13. Is the Applicant involved in any franchise operations? Yes No
Temporary Staffing Agencies
New Business Application
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© 2017 Philadelphia Consolidated Holding Corp.
04/2017
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SECTION II – LIABILITY
1.
Professional Liability (E&O)
a. Quote Requested? Yes No
b. E&O has been continuously in force since:
c. Current form type: Occurrence Claims Made
If Claims Made, current retroactive date:
d. E&O limit requested: $
e. Deductible requested: $
2.
General Liability
a. Quote requested? Yes No
b. Limit Requested: $1,000,000/$2,000,000 Other: $
Damages to Premises Rented to You: $1,000,000 Other: $
Medical Expense: $10,000 $25,000
c. Bodily Injury/Property Damage Deductible requested:
$1,000 $2,500 $5,000 $10,000 Other: $
3.
Stop Gap Coverage
a. Quote reque
sted? Yes No
b. Total payroll in each monopolistic workers compensation state:
North Dakota: $ Ohio: $
Washington: $ Wyoming: $
4.
Employee Benefits Liability (EBL) Coverage
a. Quote requested? Yes No
b. Each Act / Aggregate Limit: $1,000,000/$2,000,000 Other: $
c. Deductible requested: $1,000 Other: $
5.
Abuse and Molestation:
a. Quote requested? Yes No
b. Does your current insurance program include Abuse and Molestation Coverage? Yes No
c. Do you provide Child Care on your premises? Yes No
d. Do you place employees at:
Day Care Centers? Yes No
Schools? Yes No
Facilities with infirmed elderly? Yes No
e. If yes to question 5. c. or d., please complete the following:
Do you have written procedures in force for dealing with sexual abuse? Yes No
Do you have a plan of supervision that monitors staff in day to day relationships, both
on and off premises? Yes No
6.
Hired and Non-Owned Auto (HNOA) Liability
a. Quote requested? Yes No
b. Does the Applicant obtain MVRs on all employees who drive for clients? Yes No
c. Does the Applicant update MVRs every year for all drivers? Yes No
d. Does the Applicant provide driver training or evaluation? Yes No
e. Does the Applicant place any long-haul drivers? Yes No
f. Does the Applicant place drivers that haul hazardous materials? Yes No
g. Does the Applicant require placements to be added to the client auto policy? Yes No
7.
Employment Practices Liability (EPL) *EPL is not available monoline.
a. Quote requested? Yes No
b. Limit Requested: $
c. Deductible requested: $
Temporary Staffing Agencies
New Business Application
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04/2017
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SECTION III - CRIME
Requested Limit Deductible
Insuring Agreement A1: Employee Theft and Client Coverage $ $
Insuring Agreement A2: ERISA Fidelity $ $
Insuring Agreement B: Forgery or Alteration $ $
Insuring Agreement C: Theft, Disappearance & Destruction – Inside the Premises $ $
Insuring Agreement D: Theft, Disappearance & Destruction – Outside the Premises $ $
Insuring Agreement E: Money Orders and Counterfeit Paper Currency $ $
Insuring Agreement F: Computer and Funds Transfer Fraud $ $
Additional Insuring Agreement: Third Party – “Off Premises” Coverage $ $
1. Are the Applicant’s financial statements prepared by an independent Certified Public
Accountant on an annual basis? Yes No
2. Are the owners involved in the daily operations of the company? Yes No
3. Are two signatures required on checks? Yes No
If yes, over what amount: $
If no, who has the authority to sign checks:
4. Do employees who reconcile bank statements also:
a. sign checks? Yes No
b. make withdrawals? Yes No
c. make deposits? Yes No
d. have access to bank checks? Yes No
e. have access to computer systems that print checks? Yes No
f. have acccess to facsimilie, signature plate, or check signing machines? Yes No
5. Will any Contract/Temporary Placements have access to client money, securities, banking
systems, wire transfer systems or any sensitive computer data? Yes No
6. Will any Contract/Temporary Placements transport money, securities, or other valuable
property outside of their client’s premises? Yes No
If yes, please describe the type of property and value:
7. Will Contract/Temporary Placements be supervised and/or monitored by your clients when
performing services on their premises? Yes No
SECTION IV – POLICY INFORMATION
Coverage Carrier Limit Deductible
Effective
Date Premium
General Liability $ $ $
Professional
Liability $ $ $
Hired/Non-Owned
Auto $ $ $
Stop Gap $ $ $
EBL $ $ $
Abuse &
Molestation $ $ $
Crime $ $ $
EBL $ $ $
Expiration
Date
Temporary Staffing Agencies
New Business Application
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© 2017 Philadelphia Consolidated Holding Corp.
04/2017
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SECTION V – GENERAL SUMMARY
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) or Professional Liability (E&O)
coverage is aware of any facts or circumstances that may give rise to a Claim under these
coverages. None, or as noted below: (provide attachment if necessary)
Temporary Staffing Agencies
New Business Application
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04/2017
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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 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.
NA
ME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
____________________________________________________
SIGNATURE DATE
SEC
TION TO BE COMPLETED BY THE
PRODUCER/BROKER/AGENT
PRODUCE
R 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)
Temporary Staffing Agencies
New Business Application
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© 2017 Philadelphia Consolidated Holding Corp.
04/2017
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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 again
st the Applicant
alleging 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
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
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.
NAM
E (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
____________________________________________________
SIGNATURE DATE
SECT
ION TO BE COMPLETED BY THE P
RODUCER/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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TEMPORARY STAFFING AGENCY NEW BUSINESS APPLICATION (Combined Commercial (Philadelphia Insurance Companies)

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