Fillable WHITE WATER RAFTING SUPPLEMENTAL APPLICATION* (Philadelphia Insurance Companies)

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WHITE WATER RAFTING SUPPLEMENTAL APPLICATION* (Philadelphia Insurance Companies)

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WHITE WATER RAFTING SUPPLEMENTAL APPLICATION*
*to accompany General Application
SUBMISSION REQUIREMENTS
• Copy of your excursion / rental sheet(s)
• Copy of waivers / releases
• Safety guidelines and / or Safety program
• Brochure(s) or website address
• Any information that will help us better understand your business
GENERAL INFORMATION
1. Named Insured:
2. Location of Operation:
3. Annual Gross Revenue: $
4. Please list any associations of which you are a member:
5. Number of years in business: Years
6. Total years of experience in this type of business: Years
GUIDE INFORMATION
1. Trips are: Guided and / or Unguided
2. Describe your guidelines for client to guide ratio:
3. Describe your pre-trip safety orientation and confirm that you have a written outline / guideline:
4. Are trip logs maintained by each guide or outfitter? Yes No
If yes, are they kept for three or more years? Yes No
5. Do guides or trip leaders have training in any of the following:
First Aid Yes No
Emergency First Response Yes No
River Rescue Yes No
Swift Water Rescue Yes No
Wilderness First Response Yes No
Other, please describe:
6. Are first aid kits and safety throw ropes carried on all trips? Yes No
7. Is a communication device(s) available on all trips
(cell phone, two way radio, etc.)? Yes No
8. Are all guides licensed per your state or government agency’s guidelines? Yes No
If yes, please provide copy(s) of guidelines or regulations.
9. Have you ever had any license or permit revoked? Yes No
If yes, please explain:
Name of Guide
Trip
Leader?
Years of
Experience
Age
Qualifications
1.
2.
3.
4.
5.
6.
7.
Attach additional sheet if necessary.
White Water Rafting Supplemental
Page 1 of 3
© 2015 Philadelphia Consolidated Holding Corp.
02/2015
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TRIP INFORMATION
1. Trips are on what class of river?
I
2. Are all guests required to wear a Type III or better PFD? Yes No
3. Are helmets offered and worn on all class IV or V water? Yes No
4. Do you provide optional wet suits for guests? Yes No
Under what circumstances, if any, would wet suits be mandatory?
5. Under what circumstances would you refuse admittance / service to a customer?
6. What is your normal operating season? to
7.
Length of trips: d
ays Duration: hours per day
8. Please describe your guidelines for minimum age requirement for guests:
9. Minimum age guidelines to raft a Class III or higher river? Years Old
10. Are two or more guides always present on Class III or higher river trips? Yes No
If no, please explain:
WATERCRAFT INFORMATION
Total Number Owned Average Number Used Daily
Rafts
Canoes
Kayaks (non-inflatable)
Inflatable Kayaks
Other:
1. Please describe your regular schedule for equipment inspection and maintenance:
RIVER INFORMATION (use separate sheet if necessary)
River Rafted
(name / description)
Class of
River
Location of River
# of People per
Water Vessel
User
Days
1.
2.
3.
4.
5.
6.
7.
8.
I % II % III % IV % V %
White Water Rafting Supplemental
Page 2 of 3
© 2015 Philadelphia Consolidated Holding Corp.
02/2015
Clear Application
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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 C RIME 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 L OSS 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: 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 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 COMMITS A FRAUDULENT INSURANCE ACT.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A C RIME 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.
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
.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR
EXECUTIVE DIRECTOR)
____________________________________________________
SIGNATURE DATE
Produced By: (Section to be completed by Producer/Broker)
PRODUCER AGENCY
PRODUCER LICENSE NUMBER AGENCY TAXPAYER ID OR SS NUMBER
ADDRESS (STREET, CITY, STATE, ZIP)
White Water Rafting Supplemental
Page 3 of 3
© 2015 Philadelphia Consolidated Holding Corp.
02/2015
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WHITE WATER RAFTING SUPPLEMENTAL APPLICATION* (Philadelphia Insurance Companies)

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Completed 29 July 2020

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