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THE GUARDIAN (SECURITY SERVICES) SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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THE GUARDIAN (SECURITY SERVICES) SUPPLEMENTAL APPLICATION
SUBMISSION REQUIREMENTS
• Currently valued insurance company loss runs for the current policy period plus three prior years –
MANDATORY
• Copy of contracts and service agreements - MANDATORY
• Latest annual audited financial statements – MANDATORY (accounts w/$50,000+ in GL/PL premium)
GENERAL INFORMATION
Name Insured:
Address:
Telephone:
Web site:
FEIN:
Date established:
License Number:
Policy proposed effective dates: to
The following operations are not eligible for this program: Private Detection Agencies, Bail
Agents, Repossession Services, Process Servers, and Fire Suppression Contractors.
1.
In regard to the Applicant’s clients, does the Applicant assume any duties not
related to security, i.e. janitorial, maintenance, housekeeping, etc.
No
If yes, describe:
2.
Provide the names of the (5) largest revenue producing clients, and a description of your duties.
1.
2.
3.
4.
5.
3.
Are the majority of the Applicant’s clients under contract?
Yes
No
If yes, how many include a hold harmless clause in favor of the client:
Please include sample copies of your standard contracts and agreements.
4.
Does Applicant sub-contract work?
Yes
No
If yes, does the Applicant require certificates and/or proof of Errors & Omissions
and Commercial General Liability insurance with limits equal to or greater than
your own?
Yes
No
5.
Is the Applicant named as an additional insured on the sub-contractor’s policy?
Yes
No
6.
What background do the principals of this organization have in the security
industry? (please include resumes)
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03/2018
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7.
Will the principals perform security operations?
Yes
No
8.
Number of supervisors:
Describe the duties of the supervisors:
9.
Annual employee turnover rate: %
10.
Does the Applicant presently carry Workers’ Compensation coverage?
Yes
No
If yes, carrier:
Policy effective dates:
If no, please explain:
11.
Training program consists of:
Written manual
On-the-job
CPR
Films
Firearms
Report writing
Powers of arrest
Classroom
Other:
Describe the Applicant’s training program(s):
12.
Pre-employment screening procedures (check all that apply):
Polygraph
Prior employment contacted
Criminal background
Drug screening
Fingerprint check
Driving record
Psychological test
Personal references
Other:
Describe the Applicant’s pre-employment screening procedures:
SECURITY GUARD SERVICE / PATROL N/A
Total number of guards
Unarmed
Armed
Supervisors
Full Time
Part Time
2.
Total number of guard hours billed to client(s) annually: Unarmed: Armed:
3.
Average number of guards per supervisor:
4.
Does the Applicant use any equipment or golf carts for patrol?
Yes
No
If yes, how many?
5.
Will the Applicant provide transportation services for the public?
Yes
No
If yes, are driving records checked on drivers?
Yes
No
6.
Does the Applicant anticipate using dogs?
(Must be leashed not to exceed 6 feet)
Yes
No
If yes, number of dogs used with: Handlers?
Without handlers?
For what purpose will the dogs be used: Bombs Drugs Airports Other:
7.
Are all armed employees licensed by the state to carry firearms?
Yes
No
If yes, how often will they have to be re-certified?
PAYROLL
1.
Employee pay scale (hourly)
Minimum
Maximum
Average
Supervisors
$
$
$
Unarmed guards
$
$
$
Armed guards
$
$
$
2.
Please provide total payroll and billable hours for the past five (5) years:
Year:
Year:
Year:
Year:
Year:
Total payroll
$
$
$
$
$
Total billable hours
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3.
LIST ANNUAL PAYROLL SEPARATELY BY CATEGORY
ARMED
PAYROLL
UNARMED
PAYROLL
SUPERVISORY GUARD SERVICES
• Airports (describe operations):
$
$
• Banks or other financial institutions
$
$
• Colleges / Universities
$
$
• Concerts
$
$
• Construction or demolition sites
$
$
• Conventions
$
$
• Escort service / Body guard service
$
$
• Fast food restaurants
$
$
• Government contracts (office building, courts, military base)
$
$
• Hospitals
$
$
• Hotels / Motels
$
$
• Housing / Residential – Mid / High income
$
$
• Housing / Residential – Low income / HUD
$
$
• Industrial (warehouse, factories)
$
$
• Liquor establishments (bars, restaurants, other: )
$
$
• Malls / Theaters / Arcade
$
$
• Museums / Galleries
$
$
• Office buildings
$
$
• Patrol cars (alarm response, patrol, other: )
$
$
)
$
$
• Religious Organization
• Retail (parking lots, outside patrol, other: )
$ $
• Retail (shoplifting, surveillance, inside, other: )
$ $
• Schools – K-12
$ $
• Special Events (describe: )
$ $
• Sporting Events
$ $
• Strike work
$ $
• Traffic control
$ $
• Utilities (water, electrical, nuclear)
$ $
• Other – (describe: )
$ $
TRANSPORTATION SERVICES
• Armored car
$ $
• ATM services
$ $
• Courier (describe commodity transported):
$ $
• Other – (describe: )
$ $
OTHER
• Clerical
$ $
• Outside Sales
$ $
• Other – (describe: )
$ $
TOTAL:
$ $
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ALARM INSTALLATION, SERVICING, MONITORING OR REPAIR
N/A
1.
Estimated annual:
a.
Payroll
$
b.
Sales
$
c.
Cost of sub-contractors
$
2.
Operations of the Applicant
(show payroll and sales for each)
Payroll
Sales
• Burglar alarms – residential
$
$
• Burglar alarms – commercial
$
$
• Fire alarms – residential
$
$
• Fire alarms – commercial
$
$
• Fire Suppression Systems
$
$
• CCTV
$
$
• Access Control
$
$
• Alarm Monitoring Operations
$
$
• Medical Alert Systems/Nurse Call Systems
$
$
• Medical Alert/Nurse Call Monitoring
$
$
• Clerical
$
$
• Sales Personnel
$
$
• Other(specify):
$
$
3.
Does the Applicant have other business ventures for which coverage is not
requested?
Yes
No
If yes, explain and advise where insured:
4.
Does the Applicant do any manufacturing?
Yes
No
4a.
Does the Applicant sell anything under their own label?
Yes
No
If the answer to either question is yes, explain:
5.
Does the Applicant sell any items other than items which are installed by the
Applicant? If yes, provide a listing of products sold:
Yes
No
Sales amount for these products: $
6.
Does the Applicant do design work for others?
Yes
No
If yes, percent of operation:
%
7.
Does the Applicant design systems without performing installation?
Yes
No
If yes, percent of operation:
%
8.
Does the Applicant install alarms or phones in vehicles, mobile equipment,
watercraft, or aircraft?
Yes
No
If yes, explain:
The Guardian (Security Services)
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9.
Does the Applicant install alarms in hospitals, nursing homes, transportation
facilities, detention or correctional facilities?
Yes
No
If yes, provide details and sales amount:
10.
Does the Applicant install or monitor alarms at chemical, fertilizer or
petrochemical facilities?
Yes
No
11.
Does the Applicant install or monitor metal, chemical, or explosive detection
devices at transportation facilities, federal buildings or post office mailroom?
Yes
No
12.
Does the Applicant monitor for home incarceration or pre-trial release?
Yes
No
13.
Does the Applicant have Workers’ Compensation coverage in force?
Yes
No
14.
Does the Applicant lease employees?
Yes
No
15.
Does the Applicant sub-contract work to others?
Yes
No
If yes, what type of work:
Are certificates of insurance obtained from ALL sub-contractors with limits equal
to or greater than your own?
Yes
No
16.
Please attach:
a.
Any descriptive or advertising literature / brochure
b.
Copy of usual performance contract with client
c.
Any hold harmless agreements executed in favor of the client
17.
Does the Applicant limit liability to a stated dollar amount (liquidated damages)
on their standard alarm contract with their client?
Yes
No
If yes:
What is the maximum limit allowed: $
What percent of contracts waive the liquidated damages clause: %
AUTOMOBILE N/A
A.
Owned automobiles: Please complete an ACORD application.
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, 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:
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5.
Does the Applicant have GPS tracking capability?
Yes
No
If yes, please check off the fleet telematics being utilized:
Plug in
Hard wired
Mobile Phone
Other:
6.
What percentage of the Applicant’s fleet is provided with these telematics
devices?
7.
Are vehicles used in a patrol capacity?
Yes
No
B.
Non-Owned Automobile
N/A
1.
Number of employees using their own vehicles on company business:
a.
For what purpose? (example: local errands, security patrol)
2.
Does the Applicant require the employee to carry personal automobile
Insurance?
Yes
No
3.
Are certificates of insurance obtained from the employees’ automobile insurers?
Yes
No
4.
Who verifies coverage, limits and carrier, and that there is no lapse of an
employee’s personal automobile policy during the term of the Insured’s
commercial automobile policy?
5.
Are any driver training programs provided to the employees?
Yes
No
C.
Hired Automobile (leased, hired, rented or borrowed, not from employees)
N/A
1.
How many vehicles are hired or borrowed each year:
2.
For what purpose?
3.
Average length of time vehicles are hired or borrowed:
4.
Annual cost incurred for all hired and borrowed vehicles: $
5.
Who provides primary liability and physical damage insurance?
6.
In which state(s) does the risk hire or borrow vehicles?
C.
Garagekeepers
N/A
1.
Does the Insured offer valet parking service, own a garage or parking lot where a
fee is charged or offer automobile repair or maintenance services to others?
Yes
No
a.
If yes, please provide details on:
i.
Training of employees:
iii.
Number of parking attendants:
iv.
Security in place at site (for example, surveillance cameras, security patrol officers):
v.
Maximum value stored in one place at any given time: $
vi.
Limits and deductible desired: $
COMPLEMENTARY GENERAL LIABILITY COVERAGE N/A
1.
Is coverage desired for damage to property in your Care, Custody or Control?
Yes
No
If yes:
Limit Options:
$25,000 $50,000 $100,000 $500,000
Other: $
Deductible Options:
$1,000 $2,500 $5,000 $10,000
Other: $
2.
Is coverage desired for Third Party Theft?
Yes
No
If yes:
Limit Options:
$25,000 $50,000 $100,000 $500,000
Other: $
Deductible Options:
$1,000 $2,500 $5,000 $10,000
Other: $
3.
Is coverage desired for Lock and Key Replacement coverage?
Yes
No
If yes:
Limit Options:
$25,000 $50,000 $100,000 $500,000
Other: $
Deductible Options:
$1,000 $2,500 $5,000 $10,000
Other: $
%
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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 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 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)
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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 agains
t the Applicant all
eging 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 W
HO 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 PRO
DUCER/BROKER/AGENT
PRODUCER A
GENCY
(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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THE GUARDIAN (SECURITY SERVICES) SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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Completed 29 July 2020

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