Rod and gun club insurance application

Transcription

1 Markel Insurance Company 4600 Cox Road, Glen Allen, VA Telephone: , Fax: applications to: Website: markeloutdoors.com Rod and gun club insurance application Markel agent number: Name of club: Phone #: Fax #: Mailing address: City: County: State: Zip code: Website: Location address: City: State: Zip: Contact person & phone number: Title: Indicate desired Limit of Liability: 500,000 occurrence / 1,500,000 1,000,000 / 2,000,000 1,000,000 occurrence / 3,000,000 Desired effective date: Section 1 - Applicant information For-profit Not-for-profit 1. Legal status: Corporation Joint Venture Limited Liability Company None FEIN: 2. Is the club Private membership or Open to the public? 3. a. Number of club members:. b. Membership dues: c. Percentage of club operations: Guided % Unguided % (if guided operations, complete Guide Supplement). 4. a. Year the club was founded:. b. Does the club have established by-laws? Yes No 5. Description of club activities: 6. Do any Additional Insureds need to be added to the policy? (Liability only) Yes No If yes, type of Additional Insured: a. Owner of premises Land owner Government entity Other: Name: Address: b. Owner of premises Land owner Government entity Other: Name: Address: Section 2 - Property and liability insurance information 1. Must be completed in full in order to receive a quote, or attach 3-5 years currently valued loss information. MAGL Page 1 of 6

2 Company Effective/expiration date Premium No. of claims Amount paid 2. Provide details of loses/incidents within the past five years with dates of loss, including amount paid on a separate sheet of paper. None 3. Has your coverage been canceled in the last five years? (Not applicable in Missouri) Yes No If yes, explain: Section 3 - Club information 1. a. Does the club own or lease its buildings: None b. Number of acres used for club operations: Owned Leased/private land None 2. a. Does the club have a caretaker to monitor the premises when not in use? Yes No If no, how often does a club member check the premises? b. If yes, does the caretaker live on premises? Yes No 3. Does the club have a: Hot tub Swimming Pool? (If yes, complete a Water Activity Supplement.) Yes No 4. Are there any other business conducted on premises? Yes No If yes, please provide details: 5. Are any operations conducted outside the United States? Yes No 6. a. Does the club provide or sell any firearms or archery equipment for non-members? Yes No If yes, indicate type and age of firearms: b. Does club provide: Gunsmithing Repair services Ammunition Reloaded ammunition? Yes No 7. Does the applicant sell or provide alcoholic beverages? Yes No Are club members allowed to bring their own alcohol? Yes No 8. a. Are members allowed to bring guests? Yes No If yes, average number of guests per month: b. Is there a guest fee? Yes No c. Receipts: 9. Does the club contract out any activities? Yes No If yes, explain: Are Certificates of Insurance required? Yes No 10. Are any of the following included in your operation? Check here if no exposure. Fishing equipment sales/rental Restaurant Archery equipment sales Firearm sales Gasoline/fuel pumps Other: General store Other: Total gross annual receipts for retail sales: Square footage of retail space: Section 4 - Safety information 1. Does the club have a written: Safety Procedure Manual Emergency Evacuation Plan available to members? MAGL Page 2 of 6

3 2. a. Is a Waiver/Release of Liability signed by non-members for all activities (including parent/legal guardian signatures for minors? Yes No b. Are signed Waivers/Release of Liability kept on file? Yes No 3. Are all employees 18 years of age or older? No employees Yes No 4. Which of the following safety items are on club premises? 50 buoyant rope First Aid Kit Mobile phones Flares Heart defibrillator 2-way radios Snake bite kit GPS Other: 5. Are club- owned or member-owned firearms/ammunition stored on premises? Yes No If yes, provide details: 6. Is property posted with no trespassing signs? Yes No 7. a. Are activities provided for members guests or children under 18 _ Yes No b. Describe Section 5 - Operations - All operations and activities must be declared. Operation No Receipts Exposure Boats Clinics/lessons Fundraisers Game bird sales to others Liquor sales (complete supplement) Private parties/social activities (complete supplement) Firearm/archery range or skeet/trap/clays (complete supplement if open to public) Rental of facilities to others Youth camps Other annual revenue Members only Section 6 - Hunting No exposure IF NO EXPOSURE SKIP THIS SECTION 1. Type of hunting equipment used: Rifle Shotgun Pistol Black powder/muzzle loading Bow Other: 2. Are hunters required to wear fluorescent orange per state regulatory agency guidelines? Yes No 3. a. Hunting stands used are: Manufactured Homemade b. Type of elevated stand: Tower Ladder Climbing Hang-on Other: and Enclosed (4-sided) Open (no sides/1 side) c. Who installs the stands Member Guest Other: d. How often are elevated stands checked for safety Monthly Seasonal Other: e. Are safety harnesses required? Yes No 4. Are children under 16 always accompanied by an adult? Yes No Section 7 - Fishing No exposure IF NO EXPOSURE SKIP THIS SECTION 1. Is ice fishing allowed: Yes No If yes complete supplement. 2. What percentage of fishing is done in a boat: % 3. Are children under 12 always accompanied by an adult? Yes No Section 8 - Boating No exposure IF NO EXPOSURE SKIP THIS SECTION MAGL Page 3 of 6

4 1. Boats are used for: Hunting Fishing Boat rental Other*: (*Complete Boat Supplement) If used for hunting, describe how boats are stabilized while shooting: 2. a. Boat activities are conducted on: Rivers Lakes/ponds Ocean Bay/inlets. b. Rivers navigated are: Class I Class II Class III Class IV Class V or higher. 3. Are boats owned/leased by: Club or Individual members? Yes No 4. Are non-members allowed to operate boats? Yes No 5. Are Coast Guard approved Personal Floatation Devices provided? Yes No 6. List club owned boats including type, length, horse power, maximum capacity and if registered the bow number: (Photos may be requested) Section 9 - Shooting activities (other than hunting) 1. a. Do you provide firearms or bows? Yes No b. Are they checked? Before each use Daily Weekly Other: No exposure IF NO EXPOSURE SKIP THIS SECTION c. Is there a maintenance program for equipment/firearms? Yes No d. Are all activities supervised by a range safety officer? Yes No 2. Is hearing and eye protection required by everyone on the shooting range? Yes No 3. Shooting competitions are: Members only Clubs only Open to the public. Number of competitions: 4. Are warning signs displayed at the entrance of the range to notify others range is in use? Yes No Archery No exposure 1. The range is: Indoors Outdoors Archery course 3-D course 2. Is there backstop material? Yes No Rifle/pistol range No exposure 1. Are fully automatic firearms allowed? Yes No 2. Are inexperienced shooters accompanied to the firing position by an experienced shooter? Yes No 3. What is the backstop/berm material? Metal Earth Other: 4. Does the range and backstop meet the NRA specifications for rifle/pistol ranges? Yes No Sporting clay, trap and skeet shooting No exposure 1. Number of shooting stations on the course? Section - 10 Club owned ATVs/golf carts/snowmobile No exposure IF NO EXPOSURE SKIP THIS SECTION 1. Does the club offer the use of approved helmets? Yes No 2. What is the minimum age allowed to use one of the above: Ride: Drive: 3. Are any vehicles ever loaned or given to club members for non-club activities? Yes No 4. Are guests allowed to drive club owned vehicles? Yes No Note: No liability coverage for individually owned vehicles or non-club activities. Fair Credit Report Act Notice: Personal information about you, including information from a credit or other investigative report, may be collected from persons other than you in connection with this application for insurance and subsequent amendments and renewals. Such information as well as other personal and privileged information collected by us or our agents may in certain circumstances be disclosed to third parties without your authorization. Credit scoring MAGL Page 4 of 6

5 information may be used to help determine either your eligibility for insurance or the premium you will be charged. We may use a third party in connection with the development of your score. You may have the right to review your personal information in our files and request correction of any inaccuracies. You may also have the right to request in writing that we consider extraordinary life circumstances in connection with the development of your credit score. These rights may be limited in some states. Please contact your agent or broker to learn how these rights may apply in your state or for instructions on how to submit a request to us for a more detailed description of your rights and our practices regarding personal information. Fraud Warning: Any person who knowingly and with intent to defraud any Insurance Company or another 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 the person to criminal and [NY: substantial] civil penalties. (Not applicable in AL, AR, CO, DC, FL, KS, KY, LA, MD, ME, NJ, NM, NY, OH, OK, OR, PA, RI, TN, VA, WA, and WV) (insurance benefits may also be denied in LA, ME, TN, and VA.) STATE FRAUD STATEMENTS Applicable in AL, AR, DC, LA, NM, RI and WV Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Applicable in CO 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 FL and OK 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 (of the third degree)*. *Applies in FL Only. Applicable in KS 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 KY, NY, OH and PA 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* (not to exceed five thousand dollars and the stated value of the claim for each such violation)*. *Applies in NY Only. Applicable in ME, TN, VA and WA 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 and denial of insurance benefits. *Applies in ME Only. Applicable in MD MAGL Page 5 of 6

6 Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Applicable in NJ Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Applicable in OR Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law. Note: Rates and coverages may not be available in all states. Coverage cannot be bound until the Company approves your completed application. The company s receipt of premium does not bind coverage until a written quote has been issued. If we do not approve your application, we will refund your premium. Applicant s signature: Title: Date: Agent s signature: Date: (Florida only) Agent license number: Thank you for choosing Markel! MAGL Page 6 of 6