MOTOR SPORTS SPECIAL EVENT(S) INSURANCE APPLICATION
BROKER INFORMATION
Broker/Agency Name: Contact Person: Address:
City State Zip Phone: Fax: E-mail Address: Website:
GENERAL INFORMATION
1. Name of Insured (Applicant):
2. Address: Street City State Zip
3. Phone: Fax:
4. Form of Business: Corporation Joint Venture Partnership LLC Other (please describe):
5. Is the insured considered: For Profit Not-for-profit Federal ID #:
6. Date of Formation: Chartered or Incorporated in What State?
7. Proposed Effective Date: Website:
EVENT INFORMATION
8. Name of Event: Type of Event:
9. Location of Event (Venue/Address):
10. Dates of Event: Set-up/tear down dates:
11. Is this an annual event? Yes No
12. Event Manager: Experience: Event Risk Manager:
13. Will this event feature any of the following: Rides/Mechanical Devices, Inflatable Attractions Petting Zoos or Animals Fireworks Liquor If any, separate applications are required
FORM NO. I/A AMERSPEC. MS.SPEC.EVT.APP (10/14) Page 1 of 15 SP # 5998329 American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and A S Insurance & Risk Services Agency. All rights reserved. 14. Maximum daily attendance:
15. Are overnight accommodations or camping facilities provided for the event attendees or contracted for by the event organizer? Yes No If yes, please provide a copy of the contract.
16. Will the event have vendors or exhibitors? Yes No If yes, do you require that each vendor/exhibitor carries insurance and lists you as an additional insured? Yes No If no, do you require a vendor hold harmless/indemnification agreement (in your favor) be signed? Yes No
17. Are there musical/entertainment performers? Yes No If yes, please list below:
Performer/Entertainer Name Type of Music/Program Does the Performer/Entertainer have insurance? Yes No Yes No Yes No
18. Please list all Additional Insureds and their relationship to the Named Insured:
Additional Insureds Relationship to Named Insured
UNDERWRITING INFORMATION
19. Responsibilities: Please specify who has responsibility for the following event day operations:
Insured Facility Subcontractor/Other (please list) Facility Maintenance Maintenance of event area Concessions - Non Alcohol Concessions – Alcohol* First Aid Parking Security* Premises Defects Transportation* Fireworks* Parade* *If the insured handles this function, a separate application is required.
Please provide copies of all facility/venue agreements and/or subcontractor agreements.
20. Is the Named Insured responsible for security during the event(s)? Yes No If no, describe security protection: If yes, please complete Section B – Security
21. Describe procedures for patron eviction and/or arrests:
22. Describe the precautions taken to prevent spectators from entering restricted areas. If an outdoor event, pleas e describe fencing and other means to prohibit entry by non-ticket holders:
FORM NO. I/A AMERSPEC. MS.SPEC.EVT.APP (10/14) Page 2 of 15 SP # 5998329 American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and A S Insurance & Risk Services Agency. All rights reserved.
23. Type of medical facility/ambulance provided?
24. Is a stage used? Yes No If yes, please describe stage: Type Height Width Permanent Temporary
25. If permanent, what systems or physical characteristics keep spectators off stage?
26. If temporary, who is responsible for set up of stage? Insured Other (please list):
27. Grandstand: Type No. Age in Years Permanent Temporary
28. If temporary bleachers used, do you require a Certificate of Insurance naming you as an additional insured from the owner of the bleachers? Yes No If yes, please attach Certificate of Insurance.
29. What percentage of attendance will be festival seating; i.e., non-reserved?
30. How long before scheduled performance time will you allow entry of spectators?
31. Are ushers used? Yes No
32. Describe number and types of gates and turnstiles:
33. What type of concessions are sold?
34. Will concessionaires provide you with Certificates on Insurance evidencing products liability with your organization as Additional Insured? Yes No Please attach Certificate of Insurance.
35. Who is responsible for pre-event inspection of the event premises?
36. Does the insured have custodial responsibility for minors? Yes No If yes, is abuse coverage desired? Yes No If yes, please complete Section A to apply for Abuse and Molestation coverage.
37. Will any other underlying coverage be provided for this event? Yes No If yes, please describe:
38. How is this event being advertised?
39. Is facility in compliance with city, state, and township building, safety, and fire codes? Yes No (NOTE: Non-compliance with codes will invalidate insurance)
40. Coverage Limit Requested Limit Required Per Occurrence: $ $ Retention: $ General Aggregate: $ $ Participant Legal Liability: $ $ Personal & Advertising Injury: $ $
FORM NO. I/A AMERSPEC. MS.SPEC.EVT.APP (10/14) Page 3 of 15 SP # 5998329 American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and A S Insurance & Risk Services Agency. All rights reserved. Damage to Premises Rented to You: $ $ Products/Comp. Ops Liability: $ $ 41. Attach a diagram of location. If event is held outdoors, describe fencing used to prohibit entry by non-ticket holders, adjacent buildings, and landscape features:
42. If your organization is a member of a trade group or sanctioning body which hold insurance and/or risk management seminars and/or meetings, indicate name of association:
43. Is this a sanctioned event? Yes No If yes, name sanctioning organization:
44. Will you have remote parking? Yes No
45. What arrangements have been made for shuttle service?
PAST INSURANCE EXPERIENCE
46. Do you presently carry insurance of this type? Yes No If yes, with which insurer?
47. Has any insurer ever canceled or refused coverage? Yes No If yes, explain:
48. Insurance experience for Past Five Years First year for the event Carrier Year Premium $ $ $ $ $ Total Insured Claims $ $ $ $ $ (Paid & Reserved
49. Description of any individual claim or reserve in excess $10,000:
A. ABUSE AND MOLESTATION (Please complete this section if you need a quote for Abuse and Molestation Coverage. If you do not need a quote for Abuse and Molestation Coverage please skip this section and continue to the next section.)
50. Does the insured have custodial responsibility for minors? Yes No If yes, is abuse coverage desired? Yes No
51. Do your employees and volunteers (paid and volunteer) employment application include questions about whether the individual has ever been convicted for any crime, including sex-related or child-abuse offenses? Yes No If yes, what is the process for dealing with a "yes" answer?
52. (a) Does your state permit you to do criminal background checks on: Yes No Employees? Yes No Volunteers? (b) If yes, do you routinely request and receive such background information on all individuals who will have contact with minors? Yes No
53. (a) Do you verify employment-related references for employees? Yes No (b) Do you verify employment-related references for volunteers? Yes No
54. (a) Do you conduct a personal interview for employees? Yes No
FORM NO. I/A AMERSPEC. MS.SPEC.EVT.APP (10/14) Page 4 of 15 SP # 5998329 American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and A S Insurance & Risk Services Agency. All rights reserved. (b) Do you conduct a personal interview for volunteers? Yes No
55. Do you have a written set of procedures for screening employees and volunteers? Yes No If yes, please forward. If no, please describe your screening process.
56. Do you have an Abuse / Molestation Policy with regard to sexual abuse? Yes No If yes, please indicate how it is transmitted to your employees/volunteers.
57. Do you have written procedures for dealing with allegations of sexual abuse? Yes No If yes, please forward. If no, please describe what your current response would be.
58. Describe how your organization supervises employees and volunteers having custody of children.
59. Describe specific policy regarding any overnight travel.
60. (a) Has your organization ever had an incident which resulted in an allegation of sexual abuse? Yes No If yes, please describe your organization's response to the allegation.
(b) Was a claim made against the organization or an individual within the organization? Yes No When did the alleged incident(s) occur?
(c) Was the case taken to trial? Yes No Civil Criminal
(d) What was the disposition of the case?
61. Regarding coverage for abuse and molestation, does your current insurance program:
Yes No Exclude coverage? Yes No Limit coverage (please forward a copy of the endorsement)? Yes No Neither exclude or limit coverage?
62. Please indicate age range of minors in your care or under the supervision of your employees or volunteers at any time.
63. Please describe your current and/or planned operations that involve the custodial care of minors.
B. SECURITY COVERAGE (Complete only if security is the responsibility of by the insured)
PART I
64. Who is primarily responsible (via contract) for liability coverage for security personnel? Insured Municipality Subcontractor
Number of security personnel on staff: Number of security supervisors:
FORM NO. I/A AMERSPEC. MS.SPEC.EVT.APP (10/14) Page 5 of 15 SP # 5998329 American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and A S Insurance & Risk Services Agency. All rights reserved. Number on premises: Number off premises:
65. Do any security personnel carry a firearm as part of their equipment while on duty? Yes No If yes, number of armed security personnel:
66. Are the security persons employed or contracted by the park? Employed Contracted ("Employed" means the individual is being paid and supervised directly by the insured. "Contract" means the existence of a written contract with another entity for security services that has insurance coverage separate from the insured's policy for security liability.) Note: If "Employed," please answer Section B., Part I, II, III, and V. If "Contracted," please answer Section B., Part I, II, III, IV, and V.
67. If applicable, please provide the estimated payroll for employed security persons.
68. Total maximum hours per day permitted at this and all other places of employment: Total maximum hours per week?
69. What are the staffing guidelines per number of patrons?
70. Are the guidelines determined by: Ordinance, or Statute? Industry standard? Yes No Other (please describe):
PART II:
71. Is there a pre-employment screening procedure? Yes No If yes, please describe:
72. Does the procedure include contacting previous employers over the previous five years? Yes No
73. Do you contact at least three personal references? Yes No
74. Is a psychological screening profile used? Yes No If "yes," what type:
75. Is a criminal background check made? Yes No If "yes," what agency is used for the criminal background check?
76. Is completion of a minimum 20 hours initial training program required before deployment? Yes No
77. Who conducts the training and what are the trainers qualifications:
78. Is a minimum of 10 hours on-site training required? Yes No
79. Is a minimum of 4 hours of annual refresher or continuing education training planned and conducted for each security employee? Yes No
80. Is each security person given a personal copy of the training/safety manual? Yes No If "yes," has each security person given the park written acknowledgment of the policies and contents? Yes No
NOTE: PLEASE INCLUDE A COPY OF THE MANUAL & A SAMPLE OF THE WRITTEN ACKNOWLEDGMENT.
FORM NO. I/A AMERSPEC. MS.SPEC.EVT.APP (10/14) Page 6 of 15 SP # 5998329 American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and A S Insurance & Risk Services Agency. All rights reserved. PART III:
81. Are the security personnel in uniform? Yes No If "yes," please describe the uniform:
NOTE: PLEASE ATTACH A PHOTOGRAPH OF ONE SECURITY PERSON IN STANDARD UNIFORM. 82. Are the security personnel identified by other than a uniform? Yes No If "yes," please describe the identification and include an example or photograph.
83. Please indicate any equipment carried or routinely available to security personnel: Flashlight Type: Size: Construction:
Handcuffs Night Stick (Is Night Stick Police Regulation? Or Other?)
First Aid Kit (including blood borne pathogen kit)
Taser/Phaser Chemicals (Mace, pepper gas)
Other:
Firearm - Caliber: .357 .38 .9mm Other: Make: Colt S&W Ruger Other: Covered Holster Type:
Is Ammunition Standard Other:
Firearm and ammunition approved and inspected by park or security company? Yes No
84. Describe capabilities of each guard for constant communications with each other, the supervisor, and park management:
85. Are dogs used in your security operations? Yes No If yes, please provide the type of dog(s), number, and describe duties.
PART IV:
86. Date the contracting company began business:
87. Is there a written agreement with contracting company? Yes No If "yes," Please enclose a complete copy of the written agreement
88. Name of contracting company's liability insurance carrier:
89. Is the park an additional insured on that policy? Yes No If "yes," please enclose a complete copy of the policy.
90. Is there an established working relationship with local law enforcement? Yes No If "yes," please describe:
91. Please attach a copy of the contracting company's employment procedures.
FORM NO. I/A AMERSPEC. MS.SPEC.EVT.APP (10/14) Page 7 of 15 SP # 5998329 American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and A S Insurance & Risk Services Agency. All rights reserved. 92. No. of contracted security personnel: No. of security supervisors:
93. Are there any suits or legal actions pending against the company? Yes No If yes, please explain in detail:
94. Is there a procedure to immediately report all incidents to park? Yes No If yes, please describe:
PART V:
95. Does the supervisor make personal contact with each security person at least once during each shift? Yes No If "yes," please describe:
96. Please explain all "no" answers.
C. LIQUOR LIABILITY APPLICATION (Please complete this section if you need a quote for Liquor Liability Coverage. If you do not need a quote for Liquor Liability, please skip this section and continue to the next section.)
97. Named Insured: Address: Street City State Zip Contact Person: Phone: Fax:
98. Name on liquor license:
99. Liquor license number: Class of license:
100. Type of facility or event where liquor will be sold: Dates coverage required: Opening and closing hours of event(s): Opening and closing hours of liquor sales:
101. Has applicant's liquor license ever been revoked or suspended? Yes No If yes, please explain:
102. Has applicant incurred claims for liquor liability during the last 3 years? Yes No If yes, please explain:
103. Has any insurer cancelled or non-renewed coverage during the last 3 years? Yes No If yes, please explain:
104. Has applicant ever been fined by alcoholic beverage control or other governmental regulator? Yes No If yes, please explain:
FORM NO. I/A AMERSPEC. MS.SPEC.EVT.APP (10/14) Page 8 of 15 SP # 5998329 American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and A S Insurance & Risk Services Agency. All rights reserved. 105. Type of beverages sold:
106. Annual Gross Sales: Liquor Sales $ Food Sales $ Other $
107. Are patrons allowed to carry alcoholic beverages onto the premises? Yes No If yes, what type?
108. Do you exercise the right of search and seizure of contraband items? Yes No If yes, how do you notify the public of this?
109. Do you maintain security personnel at entry check points? Yes No If yes, what type?
110. Are the alcohol sales and consumption: Contained within one fixed site, or Are booths/stands located throughout the event site?
111. Number of servers used? Professional? Yes No Explain: Volunteer? Yes No Explain:
112. Do the servers receive any type of alcohol awareness training? Yes No If yes, please explain: (attach training manuals used)
113. Median age of liquor customers: 21-25 25-30 30-40 40 and over Are minors allowed to enter the location where alcohol is being served? Yes No If yes, how is underage consumption of alcohol prevented?
114. Explain how ID's are checked:
115. Are uniformed police officers present at the site of alcohol sales? Yes No If yes, how many? Are undercover police officers present? Yes No If yes, how many? Are private security officers present? Yes No If yes, how many?
116. Are rules and regulations clearly displayed for patrons viewing? Yes No Describe:
117. In what size of container is the alcoholic beverage served? Cup Oz. Pitcher Other
118. Is there a limit placed on the quantity of alcoholic beverages purchased at one time? Yes No Explain:
119. Is there entertainment provided? Yes No Live music? Yes No Disc Jockey? Yes No
FORM NO. I/A AMERSPEC. MS.SPEC.EVT.APP (10/14) Page 9 of 15 SP # 5998329 American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and A S Insurance & Risk Services Agency. All rights reserved. Type of music:
120. Is the parking area patrolled to prevent intoxicated drivers from leaving the premises? Yes No Explain:
121. Is there any type of designated driver program? Yes No Explain:
122. Is there any other underlying liquor liability coverage being provided? Yes No Explain:
123. Will there be additional limits of liquor liability purchased? Yes No If yes, what is the additional limit?
D. PYROTECHNICS (Please complete this section if you need a quote for Pyrotechnics Coverage (scoreboard fireworks, etc.). If you do not need a quote for Pyrotechnics, please skip this section and continue to the next section.)
124. Limit of liability requested: $1,000,000 Other:
125. Description of Events:
126. Location of Events: Street City State Zip
127. Dates of Events:
128. Who is the Authority having jurisdiction over the use of pyrotechnics at your facility? 8 Local Fire Department State Fire Marshal Other (please list): 9 129. What permit process must be followed prior to use of pyrotechnics at your facility:
130. Have you staged pyrotechnic displays before? Yes No If yes, please list any claims/losses that have occurred and the amount of loss:
Description Date of Occurrence Amount of Loss A. B. C.
131. Who will be the pyrotechnics operator?: Named Insured Contractor
Complete this section if the Pyrotechnics Operator is the Named Insured A (a) List names of people shooting fireworks and describe their experience. Please note: This coverage will exclude Bodily Injury Liability to the fireworks shooter.
Name Experience
(b) Where are the pyrotechnics stored when not in use? Does it meet Federal/State Storage Regulation? Yes No
FORM NO. I/A AMERSPEC. MS.SPEC.EVT.APP (10/14) Page 10 of 15 SP # 5998329 American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and A S Insurance & Risk Services Agency. All rights reserved. What quantity of pyrotechnic material is stored on site (pounds, # of shows, etc):
Describe the type and amount of pyrotechnics used in recurring events (e.g. facility introductions, home runs, etc.):
Describe what fire prevention and suppression measures are taken to support the pyrotechnic loading and firing process:
Do you secure proper pyrotechnic permits for each event? Yes No
Are the shooters listed above licensed for pyrotechnics? Yes No
Complete this section if the Pyrotechnics Operator is a Contractor.
(a) Name:
(b) Is there an agreement with the contractor? Yes No If yes, please provide a copy of the agreement. (c) Will liability coverage be provided by the pyrotechnics contractor? Yes No If yes, please indicate limits of coverage provided: $1,000,000 Greater than $1,000,000 Other:
Please attach a copy of certificate of insurance including any additional insured listing
(d) Do you confirm that the contractor has secured the proper pyrotechnic permits for each event? Yes No
(e) Describe what fire prevention and suppression measures are taken to support the pyrotechnic loading and firing process:
132. Do you allow tenant users (including temporary tenant users) to conduct pyrotechnic displays either themselves or through a contractor? Yes No If yes, what steps are taken to ensure that the appropriate permits are granted, appropriate fire safety codes are met, and that insurance has been obtained from either the tenant or the tenant’s contractor which lists you as an Additional insured?
If no, does the tenant lease/use agreement indicate that pyrotechnic displays are not permitted? Yes No
133. Are events with pyrotechnics held: Indoors Outdoors
134. What type of pyrotechnics will be displayed (as defined in NFPA code 1126)? Aerial Shells Airbursts Black Powder Comets Concussion Effects Concussion Mortars Electric Matches Flares Flash Pots Flashpowder Gerbs Integral Mortars Mines Mortars Rockets Saxons Waterfall, Falls, Park Curtains Wheels Salutes Other, please list:
OUTDOOR PYROTECHNICS (only complete if outdoor pyrotechnic displays are staged)
135. Are the events in compliance with NFPA 1123 or 1126 (Code for Fireworks Display)? Yes No
136. Is there fencing to keep spectators away from restricted areas during the fireworks shooting? Yes No If yes, distance of spectator fencing from launch site: Distance of spectator parking area from launch site: Distance of closest building or structure from launch site:
FORM NO. I/A AMERSPEC. MS.SPEC.EVT.APP (10/14) Page 11 of 15 SP # 5998329 American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and A S Insurance & Risk Services Agency. All rights reserved. 137. Will there be firefighting equipment on site during the event? Yes No
138. If no firefighting equipment on site, give distance to nearest fire station:
139. Will you have an ambulance on site? Yes No If no, (a) what is the estimated response time of an ambulance? (b) distance to nearest medical facility:
INDOOR PYROTECHNICS (only complete if indoor pyrotechnic displays are staged)
140. Are the events in compliance with NFPA 1126 (Standard Code for the Use of Pyrotechnics before a Proximate Audience)? Yes No
141. Is the facility sprinklered? Yes No
142. What other form of fire fighting equipment is available at the facility?
143. Does the facility have an emergency evacuation plan? Yes No If yes, how often is the staff drilled on emergency evacuation?
144. Number of accessible (not locked) emergency exits at the facility:
145. What steps are taken to inform patrons of the locations of all emergency exits?
146. Maximum capacity of the facility:
147. Has the fire marshal approved the use of pyrotechnics at the facility? Yes No If yes, as of what date:
Please provide the following with this application:
Five years of company loss runs. Most current audited financials. Copy of expiring policy or specific manuscript endorsements that the insured would like to submit for consideration. Copy of Waiver and Release and/or Assumption of Risk document that participants are required to sign. Copy of contract if overnight accommodations or camping facilities provided for the event attendees or contracted for by the event organizer Copy of illustrated diagram of event site A list of all locations to be insured, including addresses and descriptions of each location. A schedule of events and all activities and ancillary events or a brochure for each event. Copies of all facility/venue agreements. A list of all insureds to be included along with a description of each. Copies of subcontractor (bleachers, concessionaires, security, pyrotechnicians) agreements or agreements between the insured and any additional insured. Copies of certificates of insurance from each subcontractor naming the insured as an additional insured. Copy of the written set of procedures for screening employees and volunteers if applicable. Copy of the written Abuse / Molestation Policy with regard to sexual abuse and written procedure for dealing with reports of abuse and/or molestation
SECURITY Provide estimated payroll for “employed” security persons
FORM NO. I/A AMERSPEC. MS.SPEC.EVT.APP (10/14) Page 12 of 15 SP # 5998329 American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and A S Insurance & Risk Services Agency. All rights reserved. Please provide a copy of the Training/Safety Manual and Acknowledgement of Receipt employees are required to sign when provided with this manual. Please provide photo of “employed” Security Guard in uniform or photo of other means that Security is identified if not by uniform. If Security is contracted, please provide a complete copy of contract, a copy of the contracted security liability policy if insured is listed as additional insured by contract, and a copy of the security firm’s employment procedures. Copy of the event Emergency/Crisis Response plan and/or Risk Management Manual
LIQUOR Liquor Liability - Copy of server training manuals
If the following coverages are requested, please complete ACORD applications:
ACORD Applicant Information 125 ACORD Property Section 140 ACORD Inland Marine Section 146 ACORD Business Income Section 810 ACORD Crime Section 141 ACORD Business Auto 127 ACORD Umbrella Section 131
Generic Fraud Warning Language:
Any person, who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
NOTICE TO RESIDENTS OF:
Alabama, Alaska, Arizona, Arkansas, California, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Rhode Island, South Carolina, South Dakota, Texas, Utah, Vermont, Washington, West Virginia, Wisconsin, Wyoming Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Maine, Tennessee, Virginia 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.
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.
District of Columbia WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
Kentucky
FORM NO. I/A AMERSPEC. MS.SPEC.EVT.APP (10/14) Page 13 of 15 SP # 5998329 American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and A S Insurance & Risk Services Agency. All rights reserved. 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. New Jersey Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
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 also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Oregon Any person who makes an intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law.
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.
AMERICAN SPECIALTY INSURANCE & RISK SERVICES, INC. for the insuring Company shall be permitted but not obligated to inspect the INSURED'S property and operations for UNDERWRITING AND/OR LOSS CONTROL PURPOSES at any time. Neither the right to make an UNDERWRITING AND/OR LOSS CONTROL EVALUATION nor the making thereof nor any report thereof shall constitute an undertaking, on behalf of or for the benefit of any insured, or others, to forecast any accident or its severity or determine or warrant that such property or operations are safe or healthful, or are in compliance with any engineering standards, rules, or regulations. The establishment of underwriting criteria and UNDERWRITING AND/OR LOSS CONTROL EVALUATIONS ARE FOR THE SOLE PURPOSE OF DETERMINING THE INSURABILITY OF CERTAIN PROPERTY AND OPERATIONS, underwriting, and seeking to reduce claims against insurance and are not for the benefit of any insured or third party. The Insured is solely responsible for the safety of its property and operations and shall not rely upon any UNDERWRITING AND/OR LOSS CONTROL evaluations or activities to determine the safety of its property or operations and shall not diminish or forego its own safety practices and procedures.
I UNDERSTAND THAT ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION MAY BE SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
I hereby represent and confirm that the above information, to the best of my knowledge, is true and correct and further certify that I have read all of the questions and answers of these applications.
I confirm that I have read and understand the individual state fraud notices which are a part of this American Specialty application for coverage. I acknowledge and understand that any person or persons who knowingly and with intent to defraud any insurance company commits a fraudulent insurance act, which is a crime, is subject to criminal and civil penalties.
IT IS UNDERSTOOD AND AGREED THAT THE COMPLETION OF THIS APPLICATION SHALL NOT BE BINDING EITHER TO THE PROPOSED INSURED OR TO THE COMPANY UNTIL ACCEPTED BY THE COMPANY OR COMPANIES IN WRITING.
Date Signature of Insured or Authorized Representative Title
Send completed form to: American Specialty Insurance & Risk Services, Inc. 7609 W. Jefferson Blvd. Suite 100
FORM NO. I/A AMERSPEC. MS.SPEC.EVT.APP (10/14) Page 14 of 15 SP # 5998329 American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and A S Insurance & Risk Services Agency. All rights reserved. Fort Wayne, IN 46804 Phone: (800) 245-2744 E-mail: [email protected]
FORM NO. I/A AMERSPEC. MS.SPEC.EVT.APP (10/14) Page 15 of 15 SP # 5998329 American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and A S Insurance & Risk Services Agency. All rights reserved.