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WATER DISTRICTS SUPPLEMENTAL APPLICATION - ILLINOIS (Philadelphia Insurance Companies)

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WATER DISTRICTS SUPPLEMENTAL APPLICATION - ILLINOIS
APPLICANT INFORMATION
Applicant Name:
Address:
Phone:
Risk Manager:
Risk Manager Email:
1.
Number of employees:
2.
Annual payroll (less clerical):
Waterworks
Sewage Disposal (plant operations)
Irrigation
3.
Population:
Latest year of census:
4.
Number of board members:
Term of the board members:
GENERAL INFORMATION
1.
Are the facilities fenced?
Yes
No
2.
Is the Applicant responsible for dams and/ or reservoirs?
Yes
No
If yes to dams, please complete the PHLY Dam Supplemental Application.
3.
Bridges:
a.
How many bridges are owned or maintained by the entity?
b.
How often are bridges inspected?
c.
How many bridges have not passed inspection?
d.
Are all inspections current?
Yes
No
e.
Are any bridges closed or condemned?
Yes
No
If yes, please provide details. Include current bridge inspection reports.
4.
Does the Applicant own any free standing transmission towers (i.e. radio & television)?
Yes
No
WATER UTILITY
Annual distribution:
Number of gallons:
Maximum annual capacity:
Number of gallons:
1.
What is the source of the water supply?
2.
How is water stored? (check all that apply)
Open reservoir
Number of gallons:
Open surface tanks
Number of gallons:
Elevated tanks
Number of gallons:
Enclosed ground level tanks
Number of gallons:
3.
Composition of pipe:
Lead: %
Cast Iron: %
Asbestos: %
Plastic: %
Clay: %
Other (specify): %
4.
Number of users:
Residential:
Commercial:
Industrial:
Agricultural:
Grundy Application-Water Districts Supplemental
PI-WDI-APP IL (12/18)
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5.
Number of:
Water Tanks:
Water Treatment Plants:
Water Towers:
6.
Is water provided to neighboring entities?
Yes
No
If yes, describe and provide copies of contracts:
7.
Is waterline construction done by the Applicant?
Yes
No
a.
What operations are sub-contracted?
b.
What are the sub-contracted costs? (if applicable) $
8.
Is the waterline maintenance done by the Applicant?
Yes
No
a.
What operations are sub-contracted?
b.
What are the sub-contracted costs? (if applicable) $
9.
Number of miles of pipe:
a.
Approximate percent of waterlines less than 8-inch diameter: %
b.
What is the age of the oldest waterline?
c.
What is the mileage of the oldest waterline?
d.
Number of miles of irrigation ditch:
10.
How often are water mains/ lines inspected by line cameras?
11.
How often are water mains/ lines cleaned?
12.
Please describe the leak detection, the maintenance program, and replacement program:
13.
Has the Applicant completed monitoring for lead in the drinking water?
Yes
No
a.
Date completed:
b.
Test results
Tap water monitoring:
Water quality monitoring:
Lead source water monitoring:
c.
If test results exceed the lead action level of 15ppb, please comment on treatment
techniques relating to (a) corrosion control (b) source water (c) public education or (d)
lead service line replacement as applicable.
d.
How often does the Applicant test?
e.
By which regulatory agent?
14.
Does the Applicant have fully computerized water system (i.e. SCADA)?
Yes
No
15.
a.
What water chemicals does the Applicant use?
b.
How are the Applicant’s water chemicals stored and secured?
16.
Has the Applicant even been cited or fined for non-compliance of required standards?
Yes
No
If yes, please provide details, copy of non-compliance notice(s) and action(s) taken to
correct problem(s).
17.
Have there been any violations of the Safe Water Drinking Act in the last five (5) years?
Yes
No
If yes, please provide details:
Grundy Application-Water Districts Supplemental
PI-WDI-APP IL (12/18)
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18.
Does the operation utilize submersible pumps below fifty (50) feet?
Yes
No
If yes, indicate horsepower: hp
a.
Is a preventative maintenance program or annual service contract in place with a well pump
operation firm?
Yes
No
b.
Please indicate (if any) the services performed on deep water pumps: (check all that apply)
Sampling of pump discharge for sediments
Bearing lubrication
Motor amperage draw
Routine checks of all packing glands
19.
Any operations/ activities conducted other than water?
Yes
No
If yes, please provide details:
WASTEWATER UTILITY
1.
Number of utility users:
Residential:
Commercial:
Industrial:
2.
What type of facility is operated:
Treatment plant
Lift stations
Pumps
3.
Type of treatment facility:
Primary
Secondary
Tertiary
4.
Processing Method:
Lagoon
Activated sludge
Oxidation ditches
Sequencing batch reactors
Micro-filtration using membrane bioreactors
Other (describe):
5.
What regulatory agency is responsible for monitoring (DEC, EPA, Health Department)?
How often?
6.
Are sewage disposal plants maintained by the Applicant?
Yes
No
7.
How is influent input monitored for toxic or hazardous waste:
8.
How are chemicals labeled and where are they stored?
9.
What is done with residual by-product/ sludge?
10.
Has the Applicant ever been fined or received a citation?
Yes
No
If yes, please explain:
11.
Are any operations sub-contracted?
Yes
No
If yes, attach certificate of insurance and a copy of any hold harmless agreements.
12.
How old is the Applicant’s system?
Year of last upgrade:
13.
a.
Number of miles of sewer line:
Storm:
Sanitary:
b.
Are storm sewers separate from sanitary sewers?
Yes
No
14.
a.
Maximum capacity (mgd):
Current usage (mgd):
b.
Number of operational sewer taps:
Number of available taps:
15.
Is regular maintenance performed?
Yes
No
Please provide a detailed description of the Applicant’s maintenance program:
16.
Are records kept for all repairs?
Yes
No
17.
Is there a replacement program in place?
Yes
No
If yes, please provide details:
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PI-WDI-APP IL (12/18)
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18.
Has the Applicant had any past/ present incidents of sewer backup to residential or commercial
property?
Yes
No
If yes, please provide an explanation:
19.
Are the following functions performed by the entity:
a.
Sewer construction
Yes
No
b.
Sewer maintenance
Yes
No
c.
What is the facility’s procedure if an illegal backup is discovered?
20.
Has the facility been cited for any pollution violation?
Yes
No
If yes, please provide an explanation:
21.
Does the facility have a methane monitoring system?
Yes
No
a.
Is the system alarmed?
Yes
No
If yes, is the facility using methane to generate power?
Yes
No
If yes, please complete the PHLY Electrical Supplemental Application.
22.
Does the Applicant have backup power for the treatment plant and lift stations?
Yes
No
23.
How often are sewer mains/ lines inspected by line cameras?
24.
How often are sewer mains/ lines cleaned?
25.
Please describe the overall type of piping used:
26.
Any operations/ activities conducted other than sewer?
Yes
No
If yes, please provide details:
AUTOMOBILE
1.
Does the Applicant hire or borrow vehicles?
Yes
No
If yes, please describe purpose and length of time vehicles are hired or borrowed:
2.
Approximately how many cars are hired or borrowed annually?
Total cost of hire: $
3.
Number of employees using their own vehicles for Applicant’s business (occasional or full-time use):
4.
For the purposes of Non-Owned Auto Liability Coverage (if applicable), does the Applicant require
that all employees who use their own vehicles for company business carry their own Personal Auto
Insurance?
Yes
No
a.
Does the Applicant confirm that the employee’s Personal Auto Insurance does not contain an
exclusion for claims arising out of the course of driving if part of your business operations?
Yes
No
b.
What limits are required? $
NOTE: If the employee does not have Personal Auto Insurance, or if the Personal Auto
Insurance policy excludes claims arising out of the employee’s use for business purposes,
Non-Owned Auto Liability Coverage, if any, may respond on a primary basis (instead of an
excess basis) subject to the terms and conditions of the Commercial Auto Insurance Policy.
5.
Does the Applicant have a full-time fleet manager?
Yes
No
If yes, please advise:
Number of years in current position:
Total number of years’ experience:
If no, who is responsible for fleet safety and maintenance?
6.
Does the Applicant have a routine maintenance program for all vehicles?
Yes
No
7.
Are maintenance records kept for each vehicle?
Yes
No
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8.
Does the Applicant’s organization utilize GPS fleet telematics devices?
Yes
No
If yes, please check off the fleet telematics being utilized:
Plug In
Hard Wired
Mobile Phone
Other:
9.
What percentage of the Applicant’s fleet is provided with these fleet telematics devices? %
10.
Does the Applicant obtain Motor Vehicle Reports (MVR) on ALL employees?
Yes
No
If yes, when?
At time of hire
Annually
Randomly (based on accidents)
11.
Does the Applicant have a formal driving policy in place with MVR standards?
Yes
No
a.
Is driving policy communicated in writing to all employees?
Yes
No
b.
Does the policy prohibit the use of cell phones / electronic messaging while driving?
Yes
No
c.
Is a signed acknowledgement form kept on file?
Yes
No
If yes, please attach a copy of signed acknowledgement.
d.
Does the Applicant have written guidelines defining an acceptable MVR?
Yes
No
If yes, attach copy of guidelines.
12.
What action is taken if an “unacceptable” driver is identified?
13.
Does the Applicant perform accident investigations for each automobile accident?
Yes
No
14.
Does the Applicant allow any newly hired drivers to operate vehicles without going through a
company-specific documented driver training?
Yes
No
15.
Describe any ongoing training provided to drivers:
16.
Describe security regarding vehicle storage:
Locked garage
Fenced lot
Lighting
Security cameras
Security personnel
Vehicle locked when unattended
Other:
EMPLOYMENT PRACTICES
1.
Please check your desired retention:
$1,000
$2,500
$5,000
$10,000
Other: $
2.
Retro Active date:
3.
Total number of employees, including directors and officers (all locations):
a.
Non-Union:
Full-Time:
Part-Time:
Temporary:
Leased:
b.
Union:
Full-Time:
Part-Time:
Temporary:
Leased:
4.
Annual employee turnover rate for the last year? %
5.
How many employees have been involuntarily terminated in the past year?
6.
Have any EEOC or NLRB charges, state or local judgments, or demand letters from proposed,
current or former employees or their attorneys been received by the Applicant in the past five (5)
years?
Yes
No
If yes, please provide complete details on a separate sheet.
7.
Has the Applicant had any lawsuits, mediations, arbitrations, or negotiated settlements entered into
with any proposed, current or former employees of the Applicant in the past five (5) years?
Yes
No
If yes, please provide complete details on a separate sheet.
8.
Is the Applicant aware of any incidents or circumstances, which might give rise to a claim under
this policy?
Yes
No
If yes, please provide complete details on a separate sheet.
Claim(s) arising from any facts, circumstances or situations mentioned in questions 5, 6 or 7 above
are excluded from coverage.
HUMAN RESOURCES
1.
Does the Applicant have a full-time human resource coordinator?
Yes
No
2.
Does the Applicant have a written annual employee evaluation?
Yes
No
3.
Does the Applicant have a written grievance procedure in place?
Yes
No
4.
Does the Applicant have a written employee handbook?
Yes
No
5.
Does the Applicant have a written EEOC guideline in place?
Yes
No
6.
Does the Applicant have a formal outreach program for terminated/ laid-off employees?
Yes
No
7.
Do all employees receive training in the proper implementation of your human resource policies
and procedures?
Yes
No
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PI-WDI-APP IL (12/18)
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8.
Does the Applicant use outside counsel for employment advice?
Yes
No
9.
Does the Applicant have the following written policies: (check all that apply)
Anti-sexual harassment
Anti-harassment (non-sexual)
Family medical leave
10.
Do the Applicant’s anti-harassment policies provide: (check all that apply)
Confidential reporting process
Protection for employees making a complaint
An alternate reporting of allegations
Grundy Application-Water Districts Supplemental
PI-WDI-APP IL (12/18)
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WINTER WEATHER FREEZE-UP PROTECTION
1. Fire Protection and Testing
a. Is the building provided with an Automatic Fire Sprinkler System (AS)? Yes No N/A
i. If yes, approximately what percentage (%) of the building is sprinklered? %
ii. If yes, what type of sprinkler system is installed? Wet-Pipe Dry-Pipe Both
iii. If yes, when possible, is the sprinkler piping primarily run within conditioned
areas designed to ensure the temperature remains above the 45°F minimum
Yes No N/A
iv. If yes, is the testing & inspection by qualified sprinkler contractor completed
within past 12 months & includes a formal winterization rev
iew?
Yes
No
N/A
v. If yes, are the alarms tied to a 24 hour UL listed monitoring company?
Yes
No
N/A
2. Emergency Water Response (domestic and AS water lines)
a. Are water shutoff valves (domestic and AS water lines) marked and readily
accessible?
Yes
No
N/A
b. Are water shutoff valves exercised (closed and reopened) at least annually?
Yes
No
N/A
c. Is the staff qualified to respond and shut off the water main during normal business
hours and off hours?
Yes
No
N/A
3. Automatic Water Shutoff Devices
a. For domestic water lines, is there a water flow detection, notification and automatic
shutoff?
Yes
No
N/A
4. Unused/Vacant Spaces
a. Does Applicant have a formal process to turn off and drain domestic water lines for
these spaces?
Yes
No
N/A
5. Unheated Areas (attics, crawl spaces, exterior wall joists)
a. Are all domestic water lines located in areas heated to at least 45°F?
Yes
No
N/A
i. If no, please describe freeze prevention measures (e.g. temperature monitoring,
heat trace, full insulation):
This section must be completed by all risks that have a location in one of the following states: AR, CT, DC, DE,
GA, IL, IN, KY, ME, MD, MA, MI, MO, NH, NY, NJ, NC, OH, PA, RI, SC, TN, TX, VT, VA, WV, WI
temperature?
1. If no, please describe freeze prevention measures (
e.g. temperature
monitori
ng, heat trace, full insulation on piping or roof):
6.
General Comments:
Grundy Application-Water Districts Supplemental
PI-WDI-APP IL (12/18)
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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.
Grundy Application-Water Districts Supplemental
PI-WDI-APP IL (12/18)
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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)
Please send submissions to:
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PI-WDI-APP IL (12/18)
Page 9 of 11
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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 alleging in
vasion 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
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)
PI-CYBE-APP (11/16)
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WATER DISTRICTS SUPPLEMENTAL APPLICATION - ILLINOIS (Philadelphia Insurance Companies)

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Completed 29 July 2020

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