Fillable WINERY QUESTIONNAIRE (Philadelphia Insurance Companies)

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WINERY QUESTIONNAIRE (Philadelphia Insurance Companies)

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WINERY QUESTIONNAIRE
APPLICANT’S INFORMATION
1.
Applicant’s Name:
2.
Location Address:
3.
Website address: www.
4.
Year business was started:
SECTION I - PROPERTY
1.
Total wine sales expected next 12 months: $
# of gallons:
Total wine sales last 12 months: $
# of gallons:
2.
3.
Does the Applicant use the facilities of others to crush?
Yes
No
If yes, what is the location?
4.
Who bottles the Applicant’s wine?
5.
Does the Applicant bottle wine for others?
Yes
No
If yes, what is the annual bottling revenue? $
6.
Does the Applicant have any caves at their premises?
Yes
No
If yes, how are they used?
7.
Does the Applicant store wine, raw stock, juice products, etc. for others?
Yes
No
If yes, please advise
a.
Total number of gallons:
b.
Maximum value of all wine stored: $
c.
Annual storage revenue: $
8.
Is the Applicant responsible for insuring the wine of others?
Yes
No
9.
Does the Applicant need wine leakage coverage over $100,000?
Yes
No
If yes:
Limit per tank: $
Aggregate limit: $
Deductible: $
10.
Does the Applicant store wine off premises?
Yes
No
If yes, please provide the addresses where the wine is stored and the total value per location:
11.
Does the Applicant generate solar power at any location?
Yes
No
If yes, what is the total capacity of the system in kilowatts?
12.
Please check all characteristics that apply.
Burglar Alarm - local
Fire Alarm – central station
Power Outage Alarms
(if unattended)
Burglar Alarm - central station
Fire Protected – building divisions
Fire Alarm - local
High and Low temperature alarms (storage and in-process)
13.
If the location is in a Public Protection Class 8 – 10, please check all that apply.
Private water supply (tower, pond, reservoir, lake or well) – on site with Fire Department connection
Nearby pond, reservoir, lake, or well on site without Fire Department connection
On-site Fire Pump – Include a description of the system and the source of the water.
Paid or Volunteer Fire Department Engine response with on-board water
Multiple fire extinguishers – rechargeable and inspected annually by an independent fire protection contractor
Multiple ingress/ egress access roads to the premises
Brush control and fire break at least 100 feet around any structure. If less than 100 feet, what distance:
Winery Questionnaire
Page 1 of 5
© 2019 Philadelphia Consolidated Holding Corp.
11/2019
Clear Application
Print Application
SECTION II - LIABILITY
1.
Does the Applicant offer wine tasting?
Yes
No
If yes, please provide details.
2.
What are the receipts from special events*, such as weddings, concerts, fundraisers, auctions,
catering, tours, etc.: $
a.
How many special events per year?
b.
List events and describe.
3.
Is there a restaurant/ deli on the premises?
Yes
No
If yes, please describe.
4.
Does the Applicant offer catering?
Yes
No
a.
Is food prepared by Applicant or others
b.
If others, is the Applicant an additional insured?
Yes
No
5.
Are any food products served other than wine?
Yes
No
If yes, provide details.
6.
Does the Applicant allow people to come to their winery to make or bottle their own wine?
Yes
No
If yes, provide details.
7.
Does the Applicant re-label or repackage any products they sell, including wine?
Yes
No
If yes, list products.
8.
How many acres are owned?
9.
How many acres are leased?
10.
Are there any owner occupied dwellings on the premises?
Yes
No
11.
Are there any employee or tenant occupied dwellings on the premises?
Yes
No
12.
Are any overnight or guest accommodations available?
Yes
No
If yes, please explain.
13.
Any horse rides, balloon rides, etc.?
Yes
No
If yes, please explain.
14.
Any tours given to the public?
Yes
No
If yes, please explain.
15. Does the Applicant use trams, tramways, hay wagons, etc.? Yes No
If yes, please explain.
Winery Questionnaire
Page 2 of 5
© 2019 Philadelphia Consolidated Holding Corp.
11/2019
Clear Application
Print Application
16.
Does the Applicant offer rides through their vineyards?
Yes
No
If yes, please explain.
17.
Does the Applicant perform work for others?
Yes
No
a.
What is the annual revenue for the following:
Vineyard management for others: $
Custom crushing: $
Wine making for others: $
Storing wine for others: $
SECTION III - OTHER
1.
Does the Applicant need Equipment Breakdown coverage quoted?
Yes
No
2.
Describe the Applicant’s quality control program and safety program.
3.
Has the Applicant ever had a product recalled?
Yes
No
If yes, please explain.
4.
Is testing conducted with records kept at each stage in the winemaking process?
Yes
No
SECTION IV - LIQUOR LIABILITY
1. Yes No Are all employees and volunteers TIPS, TAM or a similar alcohol awareness trained?
If no, what is the training procedure?
2. Yes No Has the Applicant’s liquor license ever been revoked or suspended?
If yes, when and explain:
3. Yes No Have there ever been any citations by a liquor control board?
If yes, when and explain:
4. What controls are there to prevent over serving?
5. What are the procedures for handling an intoxicated patron:
Winery Questionnaire
Page 3 of 5
© 2019 Philadelphia Consolidated Holding Corp.
11/2019
Clear Application
Print Application
SECTION V - ADDENDUM
Wine Special Events include:
•
On side special events
•
Weddings – all sizes
• Regional or appellation events such as “Barrel Tasting Weekends”, “Passport Weekend”, etc.
(these events are counted per event, not per day)
•
Concerts including all day music festivals
•
Other music events with 50 or more people in attendance
•
Club Member release parties
•
Special tasting events
•
Events such as “Dinner with the Winemaker” if over 50 people in attendance
•
Open House Events
• Other on site special events not typically contemplated
Special Events does not include:
•
Small winery lunch, dinners, or meetings where the facility is rented to a third party
•
Evening jazz or other music events with fewer than 50 in attendance
•
Art shows or festivals
• Special Events not held at the winery facility such as an event at a restaurant where the winery is
pouring wine
Winery Questionnaire
Page 4 of 5
© 2019 Philadelphia Consolidated Holding Corp.
11/2019
Clear Application
Print Application
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 PRINCIPAL, PARTNER OR OFFICER)
_____________________________________________________________
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)
Winery Questionnaire
Page 5 of 5
© 2019 Philadelphia Consolidated Holding Corp.
11/2019
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WINERY QUESTIONNAIRE (Philadelphia Insurance Companies)

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Completed 29 July 2020

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