Fillable ZOOLOGICAL SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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ZOOLOGICAL SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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ZOOLOGICAL SUPPLEMENTAL APPLICATION
ACCOUNT INFORMATION
Applicant Name:
Address:
Web Site: www. E-Mail Address:
Effective Dates Requested:
Nature of Business / Description of Operations / Events:
Insured is: Corporation Partnership Joint Venture Other:
Estimated number of events:
1. Type of Institution: Zoological Park Wildlife Park
2. Institution is: For Profit Non Profit
3. Additional Insureds Requested (subject to underwriting approval)
Name: Relationship to Insured:
4. Is your current program: First Dollar? Self Insured Retention?
If Self Insured what is your Retention Limit? $
Insurance Limit: $
Insurance Company:
Attach four years loss history (including current year).
5. Attendance:
Average Daily Attendance:
Maximum Daily Attendance:
Total Annual Attendance:
SUBMISSION REQUIREMENTS
•
Currently valued, carrier-generated Loss Runs for the current year and the three prior years
•
Financial Statement – Current and prior year
•
Copy of most recent AZA and USDA inspection
•
SOV
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Revenues:
Admission Charge: $
Souvenir / Gift Shop Receipts: $
Concessions:
Food / Beverage: $
Alcoholic Beverage: $
Total Concessions Receipts: $
Are concessions contracted to others? Yes No
Endowments / Grants:
Contributions: $
Memberships: $
Other: $
6. TOTAL ANNUAL REVENUES: $
7. Liability Limits Requested:
A. Occurrence Form:
Each Occurrence:
$
General Aggregate: $
B. Deductible Limit (if any) $
Self-Insured Retention Limit $
Aggregate Limit $
8. Description of Operations (Attach list if necessary)
A. General Information – Mark all that apply:
Museum Watercraft Novelty / Gift Shop
Tram / Monorail / Train(s) Lake(s)/Pond(s)/Stream(s) Concessions
Breeding Facility Breeding Loan Activities Other Loan Activities
Alcoholic Beverages
Sold Gratuitous
Whose responsibility is the liquor liability?
If contracted, does the liquor concessionaire provide liability coverage? Yes No
If “no” please explain:
Carts, Vans, Buses, Motorcycles or ATVs
On Premises Off Premises
Veterinary Services
Veterinarian – Employed Veterinarian - Contracted
Off Premises:
Institution: Describe:
Captive Facility: Describe:
Breeding Facility: Describe:
Wildlife Exhibitions: Last Wildlife Exhibited:
On Premises:
Institution: Describe:
Captive Facility: Describe:
Breeding Facility: Describe:
Wildlife Exhibitions: Last Wildlife Exhibited:
Zoological Supplemental Application
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B. Educational (check, if any): On Premises Off Premises*
Lectures Tours
School Presentations Demonstrations
College Work / Class Research Program Docent Program
* Describe any off-premises activities including live wildlife exhibitions:
C. Research
Separate Research Library Formal Research Project(s)
Describe:
D. Special Events / Activities / Attractions
Fireworks Displays Concerts Other Performances
Describe:
Parking Lot Events
Describe:
Special Functions (social, political events, etc. – Attach Schedule)
Describe:
Holiday or Other Seasonal Promotions
Describe:
Publications
Describe:
Fund Raisers
Describe:
Mechanical Rides (carnival / amusement)
Describe:
Animal Rides
Describe:
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Water Rides:
Describe:
Habitat Rides
Describe:
Animal Mascot Loan
s
Describe:
Petting Zoo Feeding Permitted? Yes No
Playground
Describe:
Other
Describe:
9. Hours of Operation:
In Season: to
Off Season: to
Describe off-season activities or promotions:
10. Institution
Opening Date: Closing Date:
11. Total Acres (off main zoo premises): Parking Spaces:
12. Professional Affiliations
A. Is the institution a member of the American Zoo and Aquarium Association? Yes No
B. Is the institution accredited by the AZA? Yes No
13. Compliance
A. Does the institution comply with:
1. All local fire codes? Yes No
If “no”, explain:
2. All local, state and federal regulations? Yes No
If “no”, explain:
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B. Does the facility comply with the Animal Welfare Act, Part 3 – Standards Subparts
D, E, and F as respects the following?
1. Facilities and Operation Standards
a. Facilities – General Yes No
b. Facilities – Indoor Yes No
c. Facilities – Outdoor Yes No
d. Primary Enclosures Yes No
e. Space Requirements Yes No
2. Animal Health and Husbandry Standards
a. Feeding Yes No
b. Watering / Water Quality Yes No
c. Sanitation Yes No
d. Employees or Attendants Yes No
e. Classification and Separation Yes No
f. Veterinary Care Yes No
g. Handling Yes No
3. Transportation Standards
a. Consignments to Carriers and Intermediate Handlers Yes No
b.
Primary Enclosures used to Transport Live Non-Human Primates
Yes No
c. Primary Conveyance (Motor Vehicle, Rail, Air, Marine) Yes No
d. Food and Water Requirements Yes No
e. Care in Transit Yes No
f. Terminal Facilities Yes No
g. Handling Yes No
A complete explanation must be given for any “NO” answer (attach sheet if necessary):
C. Attach copies of:
1. All licenses, including:
USDA Registered Exhibition License License #:
USDA Licensed Exhibitor and any other required USDA Licenses
2. Most current USDA Inspection Report
D. Are any staff members under investigation for alleged violation of any wildlife
regulations?
Yes No
If “yes”, explain:
14. Security
A. Number and type of personnel:
EMPLOYEES OFF-DUTY POLICE
OTHER INDEPENDENT
Armed Unarmed Armed Unarmed Armed Unarmed
Full – Time
Part – Time
CONTRACTORS
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B. Are all the applicant’s security guard employees licensed by the State as a
security guard?
Yes No
If “no”, explain:
C. Are background investigations and checks conducted on all employees who
perform security duties?
Yes No
If “yes”, mark appropriate box:
Criminal Background Checks Previous Employer Motor Vehicle Report
Fingerprints Drug Screening Personal Reference
Background Cleared Prior to Hire Other:
What firearm training is required for armed security employees
?
Does applicant have a formal training program for security employees? Yes No
If “yes”, explain or attach a copy of training manual.
D. Describe after-hours and off-season security plans:
E. Are tranquilizer guns or dart guns loaned or taken off premises at any time? Yes No
If “yes”, describe:
F. Describe any alarm system present, including burglary or theft prevention measures:
G. Are guard dogs used? Yes No
If “yes”, explain procedure:
Provide the number of dogs to be used in your security operations:
15. Enclosure System
A. Describe the primary enclosure systems for all habitats including patron separation distance / height
(attach sheet if necessary):
B. Describe the general minimum specifications for all other primary enclosures:
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C. Describe the secondary enclosure system (premises perimeter fencing, etc.)
D. Is there a separate performance area for animal acts? Yes No
If “yes”, describe the type of animals involved and how they are transferred to and from performance
areas:
E. Detail any breaches of any enclosure systems within the past five years:
16. Employees
A. Number of employees: Full – Time Part - Time
If volunteers are used, explain their responsibilities:
B. Explain Employee Training Methods:
17. Loaned Animals:
A. Describe the written policy regarding loans to others (attach copy).
B. Describe the written policy regarding loans to the institution (attach copy).
C. Describe non-owned animals exhibited at the institution:
18. Animal Waste Treatment / Disposal
A. Explain the procedures for waste removal, treatment and / or disposal:
B. Are all waste treatment / disposal permits obtained and ordinances complied with? Yes No
If “no”, explain in detail:
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19. Is “Hands On” activity for any of the following permitted:
A. Poisonous snakes (except employee handlers)? Yes N
o
B. Adult male elephants (over the age of 10)? Yes No
C. Horned Animals? Yes No
D. Primates? Yes No
E. Off-premises exhibitions? Yes No
Explain all “Yes” answers in detail, including safety measures used:
ADDITIONAL INFORMATION – Please include copes of:
• Institution Map / Diagram • All Licenses Permits
• Animal Loan Agreement • Venomous Animal Injury Plan
• Sample copies of all contracts, including those
described in the application
• Detailed 4-Year Loss Summary (including current
year)
• Animal Acquisition / Disposal Plan • Employee Training Manual
• Amusement / Carnival Ride Description • Patron / Employee Emergency Evacuation Plan
• Institution Schedule, including Special Events,
Promotions, Exhibitions
• Animal Recapture Plan
• Liquor License (if alcoholic beverages are sold)
ABUSE AND MOLESTATION N/A
1.
Yes No
2. A. Does your state permit you to do criminal background investigatio
ns? Yes No
B. If “yes”, do you routinely request and receive such background investigations? Yes No
3. Do you verify employment related references? Yes No
4. Do you conduct a personal interview? Yes No
5. Do you have written procedures for dealing with sexual abuse? Yes No
If “yes”, please attach a copy.
6. Do you have a plan of supervision that monitors staff in day-to-day relationships with
clients, both on and off premises?
Yes No
7. A. Has your organization ever had an incident which resulted in an allegation of
sexual abuse? If “yes”, please describe below.
Yes No
B. Was a claim made against the organization? Yes No
C. Was the case settled? Yes No
D. Was the case taken to trial? Yes No
E. How much money was paid as damages to the victim? $
8. Regarding coverage for abuse & molestation, does your current insurance program:
A.
Exclude coverage
B. Limit coverage (please indicate limit of liability.) $
C. Neither exclude nor limit coverage.
9. Please indicate age range of clients:
Remarks:
Does your employment process include verification of whether the individual has ever
been convicted of any crime, including sex related or child-abuse related offenses,
before an offer of employment is made?
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LIQUOR LIABILITY N/A
1. Liquor License Name:
2. Liquor License Number:
3. Class of License:
4. Is coverage for a specific event? Yes No
5. Opening and Closing Hours of event(s) (for each event):
6. Opening and Closing Hours of alcoholic beverage sales for each event:
(Must cease a minimum of ½ hour before event closing):
7. Has your alcoholic beverage license ever been revoked or suspended? Yes No
If “yes”, explain:
8. Have you had any occurrences that have arisen out of the sale of any alcoholic beverage? Yes No
If “yes”, explain:
9. Has your liquor liability insurance been canceled or non-renewed in the last 3 years? Yes No
If “yes”, explain:
10. Have you ever been fined by alcoholic beverage control or other governmental regulator? Yes No
If “yes”, explain:
11. Type of alcoholic beverages sold: What proof? %
12. Annual Gross Sales:
Event Alcoholic Beverage Sales Food Sales
$ $
$ $
$ $
$ $
$ $
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13. A. Are patrons allowed to carry alcoholic beverages onto the premises? Yes No
If “yes”, what type?
B. Number of servers used:
C. Professional? (2 years bartender experience or more?) Yes No
Explain:
D. Non-professional? (No bartender experience)? Yes No
E. Do all servers receive any type of formalized alcohol awareness training? Yes No
If “yes”, explain who provides and are copies of certificates available?
F. Does your training include the following:
1. Identify underage drinkers and false ID’s? Yes No
2. Recognize intoxicated customers? Yes No
3. How to handle intoxicated persons and recording of incidents? Yes No
4. Understand liability associated with Liquor claims? Yes No
14. Are the alcohol sales and consumption contained by fencing within one fixed site or are
booths / stands located throughout the event site (at each event)?
Yes No
15. If site is completely enclosed, are minors allowed to enter? Yes No
16.
At what location are ID’s checked and how often?
17. In what size container are alcoholic beverages served?
Glass / Cup oz. Pitcher oz. Other:
18. Is there a limit placed on the quantity of alcoholic beverages purchased at one time? Yes No
Explain:
19. Is there any type of designated driver program in effect? Yes No
20. Are rules and regulations clearly displayed for patrons’ viewing? Yes No
Explain:
21. Is there any other liquor Liability coverage being provided? Yes No
22. Liability Limits Requested: $ Per occurrence $ Aggregate
NON-OWNED / HIRED AUTOMOBILE N/A
1. Do you have a Business Auto policy for owned autos? Yes No
If “yes”, can coverage be obtained under your Business Auto Policy? Yes No
If “no”, please explain:
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NON-OWNED LIABILITY
1. Do employees or volunteers routinely use their autos for company business? Yes No
If “yes”, please provide details regarding duties involved:
2. Do you verify that insurance is in place with limits of at least $300,000 before employees
or volunteers can use their auto?
Yes No
3. Do you run motor vehicle reports on each employee? Yes No
4. Please explain what other controls you have in place to protect your company’s liability.
5. Number of Employees: Volunteers:
HIRED AUTO LIABILITY
1. During the last three years, have you leased, borrowed or hired any vehicles for your
business?
Yes No
2. If you anticipate some usage this year:
A. What type of vehicles (trucks, cars, buses)?
B. What is the estimated cost to lease or hire the vehicles?
3. When leasing, hiring or borrowing, are the vehicles used to:
A. Transport participants, volunteers or staff only? Yes No
If “yes”, how many?
For how long?
B. Haul Equipment Yes No
If “yes”, please explain and identify frequency and distance traveled per trip:
4. If using buses or vans, please answer each of the following:
A. Maximum number of passengers each vehicle carries:
B. Distance traveled per trip:
C. How long the vehicles will be used:
D. Year Built:
E. Cost New: $
5. Does the leasing company provide drivers or do you use your own?
6. Do you purchase liability insurance from the leasing company? Yes No
7. Does the vehicle owner(s) require you to provide primary insurance and to add them as
additional insureds?
Yes No
If “yes”, please explain:
8. What is the estimated annual cost to hire / lease all vehicles? $
9. Do you hire vehicles for more than or less than 30 days for any one time? More Less
If more than 30 days, vehicles should be scheduled.
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HIRED AUTO PHYSICAL DAMAGE
1. What types of vehicles have you leased or do you intend to lease (Make / Model / Size)?
2. What is the highest value vehicle you have leased or intend to lease? $
3. Do drivers share in the loss exposure (i.e. driver pays half of the deductible)? Yes No
4. What is the maximum number of vehicles leased at one time?
5. Please provide the garage location of the vehicles (city and state):
6. Requested Comprehensive Deductible: $ Collision Deductible: $
LIST OF DRIVERS – Please provide the following information for each driver:
Name Birth Date Driver’s License No. State Licensed
LEASED VEHICLES
If leased, what is the term of the lease?
Vin # Year Make Model New Cost
Garage Location
(City and State)
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N/A
THIS SECTION IS AN APPLICATION FOR A CLAIMS MADE POLICY.
PLEASE READ YOUR POLICY CAREFULLY.
DIRECTORS & OFFICERS LIABILITY INFORMATION
1.
Does the Applicant have a tax-exempt status under the U.S. Internal Revenue Code?
Yes
No
If no, provide an explanation:
2.
FINANCIAL INFORMATION
CURRENT FISCAL YEAR
PREVIOUS FISCAL YEAR
Total Assets:
$
$
Net Assets / Fund Balance:
$
$
Annual Revenue:
$
$
Net Revenue:
$
$
3.
Provide a list of all direct and indirect subsidiaries or any other entity or organization the Applicant controls:
Name / Type of Business
Percent the Applicant
Owns/Controls
Date Created /
Acquired
For Profit /
Non-Profit
I.E.: ABC Foundation / Charitable Foundation
100%
01/01/2000
Non-Profit
%
%
%
Additional entities listed by attachment
4.
Has the Applicant or any person proposed for coverage herein been the subject of, or
involved in, any of the following in the past five (5) years? If yes, please attach details.
Yes
No
Any disciplinary action by any regulatory agency or association?
Yes
No
Any administrative proceeding charging violation of a federal or state law or regulation?
Yes
No
Any other criminal actions?
Yes
No
5.
In the past 24 or next 12 months has the Applicant been, or anticipate being involved in
any merger, acquisitions or consolidation with another entity?
Yes
No
If yes, please attach details.
EMPLOYMENT PRACTICE LIABILITY INFORMATION:
1.
Please provide the following employee count information:
U.S. based employees:
Total Full-Time:
Total Part-Time:
Volunteers:
Temporary:
Leased:
Total Non U.S. based employees:
TOTAL SUM OF ABOVE:
2.
Has a reduction in employees or change in of status occurred in the past 12 months or is
anticipated in the next 12 months?
Voluntary:
Involuntary:
Layoffs:
3.
Does the Applicant have an employment handbook that includes an “At Will” statement?
Yes
No
4.
Does the Applicant use an employment application for every potential employee?
Yes
No
5.
Does the Applicant use outside employment counsel for employment advice?
Yes
No
6.
Does the Applicant have a full time, dedicated human resource staff?
Yes
No
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7.
Total number of current employees with annual compensation greater than $100,000:
CURRENT COVERAGE:
COVERAGES
Insurance Company
Limit of
Liability
Deductible
Policy Effective
Dates
Premium
D & O
$
$
$
EPLI
$
$
$
Fiduciary
$
$
$
Workplace
Violence
$
$
$
Internet Liability
$
$
$
WARRANTY INFORMATION:
1.
With respect to this coverage, has any Underwriter refused, canceled or non-renewed
coverage? (Not Applicable in Missouri)
Yes
No
If yes, please provide details:
2.
Has the Applicant given written notice under the provisions of any prior policies providing
similar insurance or 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?
If yes, complete a Claim Supplemental for each incident.
Yes
No
3.
No person applying for this coverage is aware of any facts or circumstances which he or
she has reason to suppose might give rise to a future claim that would fall within the
scope of any of the proposed coverages for which the Applicant has applied, except:
None or as noted below.
With regard to questions 2. and 3., it is understood and agreed that if any such claim, act, error, omission,
dispute or circumstance exists, then such claim and/or claims arising from such act, error, omission,
dispute or circumstance is excluded from coverage that may be provided under this proposed insurance
and, further, failure to disclose such claim, act, error, omission, dispute or circumstance may result in the
proposed insurance being void, and/or subject to rescission.
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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
SE
CTION 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 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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ZOOLOGICAL SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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Completed 29 July 2020

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