Insuring the world s fun

Transcription

1 SKATING FACILITIES Eligible Operations: - Ice skating arenas - In-line hockey facilities - Roller rink facilities Key Underwriting/Qualifying Factors (Including but not limited to): - Must utilize appropriate waiver & release with established procedures to obtain signatures - $5,000 minimum general liability premium Ineligible for this program: - Ice operations on natural waterways (ponds, lakes and streams) - In-line skate activities held in parking lots or similar areas - Non-supervised operations - Skate parks K&K Benefits: - Experienced & professional staff dedicated exclusively to servicing the K&K Skating Facility Program for over 20 years - Proud members and sponsors of the North American RINK Conference & Expo (NARCE), STAR Member Rinks, Ice Skating Institute (ISI), and other regional organizations - Active participation in industry trade shows and meetings - Over 65 years of experience providing sports, leisure and entertainment insurance - In-house underwriting, policy administration and claims services - Carrier supported loss control services - 24-hour emergency claims phone service - Insurance carriers rated A or higher by A.M. Best - Premium installment plans available This program was developed for ice arenas, in-line hockey facilities and roller rink facilities with operations including leagues, instruction and recreational skating as well as ancillary operations such as concessions, pro shops, etc. Our program offers competitive pricing, superior coverage forms, experienced claims handling, and a service commitment to the skating industry. Coverages Available & Program Highlights: Property - Equipment Breakdown Included - Newly Acquired or Constructed Building - Newly Acquired Business Personal Property - Ordinance & Law - Off-premises Power Failure - Water Back-up of Sewers & Drains - Outdoor Signs - Outdoor Property (trees, shrubs or plants) - Property Off Premises - Accounts Receivable/Valuable Papers & Records - Replacement Cost Defined - Covered Property Definition Redefined General Liability - Written on an Admitted Basis in Most States - Broadened Coverage Form - Non-auditable Policy - No Deductible - No General Aggregate - Legal Liability to Participants - Liquor Liability - Stop Gap Liability - Employee Benefits Liability Inland Marine Crime Commercial Auto Excess Liability Workers Compensation Directors & Officers Not for Profit Event Cancellation & Non-appearance Common Associated Exposures: - Food concessions - Sports complex - Internet sales activities - Health & fitness areas - Sports day camps - Pro shops - Vending & arcade - Restaurant w/liquor operators Insuring the world s fun

2 Submission Instructions: To request an insurance quotation through this program, please submit the appropriate applications along with the preliminary underwriting information listed. In some cases, requested coverages may not be offered or available due to underwriting criteria and/or carrier guidelines. It is important to carefully review the terms and conditions of any insurance quotations received. Please contact a K&K representative if you have any questions. Preliminary Underwriting Information Required: - Application(s) (see below) - ACORD application(s) for other requested coverages - Five years of carrier loss runs - Facility brochure (if available) - Copy of waiver & release forms - Copy of facility rental contract Contact Information: 1712 Magnavox Way P.O. Box 2338 Fort Wayne, IN Skating Facilities Program PHONE: FAX: KK.Recreation@kandkinsurance.com WEB SITE: kandkinsurance.com Skating Facilities Application(s): (Applications can be obtained from our web site: kandkinsurance.com) K&K Application(s) - Ice/In-line Skating Facility Supplemental ACORD Application(s) - Property - Crime - Commercial Auto - Inland Marine - Excess Liability - Workers Compensation (subject to state availability) K&K Insurance Group, Inc. is a licensed insurance producer in all states (TX license #13924); operating in CA, NY and MI as K&K Insurance Agency (CA license # ) Insuring the world s fun 2/17

3 1712 Magnavox Way P.O. Box 2338 Fort Wayne, IN Fax CA# ROLLER SKATING FACILITY GENERAL LIABILITY INFORMATION FORM GENERAL INFORMATION Name of agency/brokerage: Proposed effective date: / / Contact person: Phone:( ) Fax: ( ) Tax ID#: address: Mailing address: City: State: Zip: BUSINESS INFORMATION Name of insured (as will appear on policy): Doing business as: Mailing address: Location address: Effective date: Expiration date: FEIN Web Site: 1. Do you own or lease facility? q Own q Lease 2. Number of years in business at this location : Years experience: 3. Facility is a member of RSA 4. Does the organization engage in any other business operations under the name of the insured as will appear on the policy? If yes, explain: 5. Are any of the insured s locations within 1/2 mile of a military base, defense contractor, major utility, known U.S. landmark, sports stadium, or a major amusement park? If yes, explain: 6. Has there been a lapse in coverage over the past 3 years? COVERAGE INFORMATION Indicate the coverages desired; note the forms to be completed. ACORD application required: q Property q Inland Marine q Crime q Auto q Excess q Workers Compensation PRIOR CARRIER INFORMATION YEAR PREVIOUS AGENT COMPANY LIABILITY LIMITS PREMIUMS Page 1 of /14

4 STANDARD OPERATIONS 1. What are your standard hours of operations? 2. Do you offer any "all night" or midnight skating? If yes, what ages are allowed? What are the hours? What time is admission no longer permitted? What are the drop-off and pick-up guidelines? What are the guidelines in place that outline who is allowed to leave the facility and at what time? 3. Number of skating surfaces: 4. Floor material: Overall condition: Age: 5. Is there regularly scheduled maintenance of the floor? If yes, briefly describe regularly scheduled skating floor maintenance and who performs the work: If work is performed by outside contractor, do you obtain a Certificate of Insurance? 6. Is the rink utilized/rented out for non-skating activities? If yes, list the events: Is there a written contract between the rink and the party utilizing/renting out facility? Do you obtain Certificates of Insurance from the party utilizing/renting out the facility? If yes, attach a sample copy. 7. Are safety rules and rules of conduct posted in conspicuous places? (Attach List of ALL signs.) 8. What job training do the employees receive? 9. Please list the days of the week and the times of day the owner/operator is on premises to manage the facility: _ 10. Who is responsible for loss control on the premises? Name: Phone number:( ) q Insured q Rink owner/operator q Landlord q Manager q Employee 11. Do you offer: q Dancing q Skating lessons q Skating competitions q Other: 12. Are instructors on premises: During sessions? Outside of sessions? Are instructors employees of the applicant? Do instructors obtain releases & waivers from students and/or parents? 13. Do you have printed job descriptions or an employee manual? 14. Do you own and refer to a Floor Staff Training Program Manual? 15. Total number of employees: How many full time employees?: 16. Maximum number of Skaters per Floor Guard during sessions: Rink Floor Capacity: 17. Do you conduct regular maintenance, inspection and replacement of rental skates? 18. Do you keep a skate maintenance log? 19. Do you number your skates? Page 2 of /14

5 20. Is there a risk assumption act within your state? Do you adhere to its safety standards and posting requirements? 21. Explain briefly the overall maintenance and housekeeping of premises: 22. Do you have a video tape monitoring system installed in the rink? Which areas are recorded? Skate floor q Snack bar q Parking lot q Off-area q Arcade q How many cameras? How long are tapes kept in storage? Years Months 23. How long do you maintain your paper trail for incidents, accidents and supporting documentation? (i.e. daily, session, monthly, skate logs, etc.): q 1 Year q 2 Years q 3 Years q 4 Years q Not at all Briefly describe how injuries and medical emergencies are handled and by whom: 24. Please give details: Gross annual receipts: $ Average number weekly patrons: Gross Annual Receipts Breakdown: General Admissions Skate Rental Lessons Arcade Food / Snack Bar Pro Shop Birthday / Private Parties Dances After School / Camp Program Day Care: q Licensed q Unlicensed Kinderskate Other: Skate Park Laser Tag Bingo q Inflatable q Soft Play Alcohol *Hockey Admissions *Figure / Speed *Teams / Leagues *Go Karts *Competitive Events **FEC Rides / Amusements *YOU MUST ATTACH SANCTION CARD, CERTIFICATE OF INSURANCE, SAMPLE RELEASE AND WAIVER ** PLEASE LIST AMUSEMENTS: SEXUAL ABUSE/MOLESTATION (If coverage is desired) 1. Do you have a formal set of policies and procedures for screening the character and criminal history of your adult staff, whether volunteers or paid employees? 2. Do you conduct criminal background checks on employees or volunteers who work with children? 3. Do you have written procedures to follow if a child, member, or employee reports an incident of sexual or physical abuse or molestation? 4. Are copies of the procedures provided to each member of your staff? 5. Have you ever had an incident which resulted in an allegation of sexual abuse at your facility? 6. Has a sexual abuse/molestation claim ever been made against your facility? If yes, explain in detail, including the amount of damages paid to the victim: What has been done to prevent such occurrences from happening in the future? Page 3 of /14

6 PARKING: A. Do you have parking facilities available? If yes: Who is responsible for repairs/maintenance? Who is responsible for snow/ice removal? Who is responsible for security? EMERGENCY MEDICAL: A. Do you have written incident reporting procedures? B. Do you provide a first aid station? If no, do you have a first aid kit? C. Do you have a written emergency medical procedure in place? D. Does the facility have an Automated External Defibrillator (AED)? E. Does your state require you to have available an AED? F Is the AED easily accessible for those who have been trained in the use of the AED? G. Do you have AED trained staff on duty during open hours? H. Do you have a written emergency evacuation plan? SECURITY: A. Who handles disturbances/fights/ejections/crowd control in your rink? B. Is security ever contracted? If yes, do you require contract with hold harmless and collect additional insured certificate? C. Is security lighting provided in your parking lot? FOOD & BEVERAGE CONCESSIONS: A. Do you have a concession operation? q Snackbar q Restaurant q N/A If yes, who operates it? q You q Subcontracted* q Square feet * If subcontracted, do you require a Certificate of Insurance with Additional Insured status? B. Provide brief description of items sold: C. Are all grills and deep fryers equipped with hoods, automatic fire suppression systems and automatic fuel shutoff controls? D. How often are hoods and filters cleaned and degreased? E. Are alcoholic beverages sold/served or allowed on premises? If so, complete Liquor Liability Application. SERVICES: A. Do you have a skate rental operation? If yes, who operates it? q You q Subcontracted* Square feet * If subcontracted, do you require a Certificate of Insurance with Additional Insured status? B. Do you have a Proshop? If yes, who operates it? q You q Subcontracted* Square feet * If subcontracted, do you require a Certificate of Insurance with Additional Insured status? Off-premises activities are not covered without proper approval from the insurer. Please list any off-premises activities, events, exhibitions, or demonstrations conducted by your facility, and how often, for approval. Page 4 of /14

7 SUBMISSION CHECKLIST 1. Fully completed & signed applications: q ACORD Applications (for all coverages requested) q Roller Skating Facility Information form 2. Five years currently valued carrier loss runs 3. Copy of Facility Rental Agreement with facility users I understand the insurance company in determining whether to provide a quotation for insurance coverage will rely on the information contained in the application and all other information being submitted. I hereby warrant, represent and confirm that, to the best of my knowledge, all information provided is complete, true and correct. Applicant s Signature Producer s Signature (if applicable) Applicant s Name (print) Date MM/DD/YY Producer s Name (print) Date MM/DD/YY Page 5 of /14

8 1712 Magnavox Way P.O. Box 2338 Fort Wayne, IN Fax CA# ICE/INLINE SKATING FACILITY GENERAL LIABILITY INFORMATION FORM GENERAL INFORMATION Name of agency/brokerage: Contact person: Phone:( ) Fax: ( ) Tax ID#: address: Mailing address: City: State: Zip: BUSINESS INFORMATION Name of insured (as will appear on policy): Doing business as: Web Site: 1. In what state is the organization headquartered/chartered? 2. Do you own or lease facility? q Own q Lease 3. Total number of full time employees: ; Part time employees: ; Volunteers: Are volunteers covered under your Workers Compensation policy? 4. Facility is a member of: q ISI q NEISMA q STAR q USA Hockey q None q Other 5. Does the organization engage in any other business operations under the name of the insured as will appear on the policy? If yes, explain: 6. Is insured a non-profit organization? 7. Are any of the insured s locations within 1/2 mile of a military base, defense contractor, major utility, known U.S. landmark, sports stadium, or a major amusement park? If yes, explain: COVERAGE INFORMATION Indicate the coverages desired; note the forms to be completed. ACORD application required: q Property q General Liability q Inland Marine q Crime q Auto q Excess q Workers Compensation q Liquor (complete Liquor Liability section) q Sexual Abuse & Molestation (complete Sexual Abuse & Molestation section) q Nonowed & Hired Auto (complete Nonowned & Hired Auto section) PRIOR CARRIER INFORMATION YEAR PREVIOUS AGENT COMPANY LIABILITY LIMITS PREMIUMS Number of YEARS in business : 1. Please list tenants, sub-contractors, and independent contractors below and indicate whether they carry their own insurance naming the rink as an Additional Insured, and what limits are carried: NAME LIMITS SQ. FEET ADDITIONAL INSURED LICENSED/CERTIFIED Page 1 of /17

9 2. As respects this operation, list the contracts entered into by this applicant, and whether the Named Insured assumes liability for the other party: ICE/IN-LINE RINK REVENUE SOURCES Based on 12 Month Income ICE RINKS INLINE FACILITIES A. GENERAL ADMISSION: Open public skate $ $ Skate rental (public) $ $ TOTAL: $ $ B. RINK SPONSORED: Recreational group lessons $ $ Figure skating lessons $ $ Hockey lessons $ $ Senior hockey league $ $ Skate sharpening $ $ Skate rental for lessons $ $ Parties $ $ TOTAL: $ $ C. FACILITY RENTAL: USA Hockey * $ $ U.S. Figure Skating $ $ Association (clubs & events) $ $ High school and college $ $ Non-skating events $ $ TOTAL: $ $ * List all USA Hockey Teams/Leagues that skate at your facility: D. OTHER: Arcade $ $ Concessions $ $ Pro Shop $ $ Vending $ Liquor $ $ Other: $ $ TOTAL: $ $ Page 2 of /17

10 INSURANCE INFORMATION 1. During open skate sessions Minimum number of employees on duty: On rink: Off rink: 2. Do you incorporate waiver wording in Open Public Skating session, either by announcement, through PA system, or wording on admission ticket for session? 3. Is Code of Conduct wording posted within facility? 4. Does your facility sponsor a hockey team or league? If yes, are they members of: q USA Hockey q Other : 5. Does your facility sponsor figure skating clubs? If yes, are they members of: q USFS q ISI q PSA q Other Any skating teams/skaters/skating exhibitions/contests/team sports sponsored by the rink? If yes, please specify: 6. Do you require facility user groups to sign a rental agreement? Please attach and provide a copy of the agreement. 7. Do you require certificate of insurance with additional insured status from facility user groups? 8. For Rink Sponsored activities (i.e.: camps, clinics, learn to skate/play programs, adult/youth hockey programs, broomball, etc.) are waivers signed by all participants or a parent/legal guardian if a minor (under 18)? 9. If you are a STAR Member, advise which courses your employees have taken and how many employees have taken the course. q Basic Refrigeration q Ice Making & Painting Technologies q Operations and Risk Management q Ice Maintenance and Equipment Operation q Human Resource Management q Programming, Marketing & Promotions 10. If you are a STAR Member, advise if any of your employee(s) hold the following STAR certifications: q Certified Ice Technician (CIT) q Certificied Rink Administrator (CRA) q Certified Rink Manager (CIRM) 11. Does your rink(s) have the Look-up line? SEXUAL ABUSE/MOLESTATION (If coverage is desired) 1. Do you have a formal set of policies and procedures for screening the character and criminal history of your adult staff, whether volunteers or paid employees? 2. Do you conduct criminal background checks on employees or volunteers who work with children? 3. Do you have written procedures to follow if a child, member, or employee reports an incident of sexual or physical abuse or molestation? 4. Are copies of the procedures provided to each member of your staff? 5. Have you ever had an incident which resulted in an allegation of sexual abuse at your facility? 6. Has a sexual abuse/molestation claim ever been made against your facility? If yes, explain in detail, including the amount of damages paid to the victim: What has been done to prevent such occurrences from happening in the future? 7. Liability limits requested: q $500,000 per person/$1,000,000 aggregate q $1,000,000 per person/$2,000,000 aggregate Page 3 of /17

11 BUILDING AND OPERATIONS INFORMATION 1. FLOOR: A. Number and type of skating surfaces: Indoor: Ice # Inline # Other Outdoor: Ice # Inline # Other B. What is the construction of the ice refrigeration equipment? q 1 inch diameter steel piping with welded connections q 1/2 inch diameter steel tubing q Plastic mat piping C. Is the piping accessible by crawl space or lower level access? If no,explain (i.e. buried in concrete, sand, gravel etc.) D. Is the ice surface ever covered or removed for other activities? If yes, do you require contract with hold harmless and collect additional insured certificate? 2. SEATING: A. Is spectator seating provided by your rink? If yes, is the seating: q Permanent q Temporary/Portable B. What is the seating capacity? C. Is there seating behind the goals? If yes, is there netting to the ceiling? D. Does the netting circle the entire rink? 3. PARKING: A. Do you have parking facilities available? If yes: Who is responsible for repairs/maintenance? Who is responsible for snow/ice removal? Who is responsible for security? 4. EMERGENCY MEDICAL: A. Do you have written incident reporting procedures? B. Do you provide a first aid station? If no, do you have a first aid kit? C. Do you have a written emergency medical procedure in place? D. Does the facility have an Automated External Defibrillator (AED)? E. Does your state require you to have available an AED? F Is the AED easily accessible for those who have been trained in the use of the AED? G. Do you have AED trained staff on duty during open hours? H. Do you have a written emergency evacuation plan? Page 4 of /17

12 5. SECURITY: A. Who handles disturbances/fights/ejections/crowd control in your ice rink? B. Is security ever contracted? If yes, do you require contract with hold harmless and collect additional insured certificate? C. Is security lighting provided in your parking lot? D. If you own or lease your skating facility and we are to consider property coverage for you, do you wish to insure the security lighting (light standards) in your parking lot? If yes, please have your agent include this important coverage on the property application for specific consideration. Include number of light standards, replacement cost or actual cash value, cost per lighting standard, and total value. 6. FOOD & BEVERAGE CONCESSIONS: A. Do you have a concession operation? q Snackbar q Restaurant q N/A If yes, who operates it? q You q Subcontracted* q Square feet * If subcontracted, do you require a Certificate of Insurance with Additional Insured status? B. Provide brief description of items sold: C. Are all grills and deep fryers equipped with hoods, automatic fire suppression systems and automatic fuel shutoff controls? D. How often are hoods and filters cleaned and degreased? E. Are alcoholic beverages sold/served or allowed on premises? If so, complete Liquor Liability section. 7. LIQUOR LIABILITY (if coverage is desired) A. Name liquor license is in: B. Liquor license number: Class of license: C. Opening and closing hours of alcoholic beverage sales: D. Has applicants alcohol beverage license ever been revoked, suspended or fined? If yes, please explain: E. Has applicant incurred claims for liquor liability during the last five years? If yes, please explain: F. Has any insurer cancelled or non-renewed coverage during the last five years? If yes, please explain: G. Type of alcoholic beverages sold: q Beer q Wine q Liquor H. Annual gross sales of alcoholic beverages: $ I. Are patrons allowed to carry alcoholic beverages onto the premises? If yes, what type? J. Name the formal awareness training program that the servers receive: K. At what point of sale are I.D.s checked? L. If there any other Liquor Liability coverage being provided? If yes, explain and attach a copy of the certificate of insurance: M. Liability limits requested: $ (per occurrence) $ aggregate Page 5 of /17

13 8. SERVICES: A. Do you have a skate rental operation? If yes, who operates it? q You q Subcontracted* Square feet * If subcontracted, do you require a Certificate of Insurance with Additional Insured status? B. Do you have a Proshop? If yes, who operates it? q You q Subcontracted* Square feet * If subcontracted, do you require a Certificate of Insurance with Additional Insured status? C. Do you have an inflatable or bounce house? If yes, how many? Is the inflatable and/or bounce house rented or owned by the insured? q Rented q Owned If rented, who is responsible for installation to ensure properly anchored? If owned, what guidelines are followed to ensure properly anchored? How is it monitored for use and by whom? Are waivers signed by participant and parent/legal guardian of minors? (provide copy of signed waiver for our files) 9. CRYOTHERAPY: Do you have a Cryotherapy chamber? If yes, provide: A. Name of the chamber manufacturer: B. An explanation or copy of the staff training program: _ C. How is the chamber operated? (i.e. controlled by member/guest or staff) _ D. Is the chamber used for medical rehab or for on-demand type voluntary use? E. Copy of waiver form being used for the chamber. 10. FLOAT TANKS: Do you have a Float Tank? If yes, provide: A. Name of the chamber manufacturer: B. An explanation or copy of the staff training program: C. How is the chamber operated? (i.e. controlled by member/guest or staff) D. Is the chamber used for medical rehab or for on-demand type voluntary use? E. Copy of waiver form being used for the chamber. 11. MAINTENANCE: A. How many ice resurfacer machine(s): Approximate total value: Are the limits included in the: Building? Business Personal Property? Inland Marine? Is regular maintenance performed? Is ice resurfacer machine ever taken off premises for servicing and/or parades? B. Are any of the facility s maintenance procedures written or logged? C. Are ice maintenance procedures written or logged? D. Does the building limit include underground pipes and flues? Page 6 of /17

14 E. Does your facility ever use a scissor lift? If yes: 1. Is it owned or rented: 2. What is the scissor lift used for: 3. Who operates the scissor lift (i.e.: employee, volunteer, entity from which scissor lift is rented/leased, independent contractor, etc.)? 4. Who is responsible for the maintenance of the scissor lift? If the named insured is responsible for the maintenance, describe maintenance schedule: 5. Is a maintenance log maintained on the scissor lift? 6. Describe the controls and safety procedures in place for the use of the scissor lift: 12. NONOWNED AND HIRED AUTO LIABILITY (If coverage is desired) A. Do you have a Business Auto Policy for business-owned autos? (If yes, you will need to add hired/nonowned auto to that policy) B. Does your operation require employees to drive their personal vehicles for company business on a regular basis? If yes, describe the reasons why they would be using their personal vehicles for company business. _ C. Do you verify that their personal auto insurance is in place with limits of a least $300,000 before employees can use their autos for company business? D. During the last three years have you leased, borrowed, or hired any vehicles for your business? E. If you anticipate some usage this year: 1. What type of vehicle (trucks, cars, buses)? 2. What is the estimated cost to lease or hire the vehicles? 3. Number per month Number per year LIST OF DRIVERS - Please provide the following information for each driver. Name Birth Date Driver s License Number State Licensed Page 7 of /17

15 SUBMISSION CHECKLIST 1. Fully completed & signed applications: q ACORD Applications (for all coverages requested) q Ice/Inline Skating Facility Information form q Public Transportation Questionnaire (if applicable) 2. Five years currently valued carrier loss runs 3. Copy of Facility Rental Agreement with facility users 4. Waiver and release forms used by your organization 5. Risks in business 3 years or less require a resume for owner and rink manager and financial proforma (12 months income, expense, and balance sheet). I understand the insurance company in determining whether to provide a quotation for insurance coverage will rely on the information contained in the application and all other information being submitted. I hereby warrant, represent and confirm that, to the best of my knowledge, all information provided is complete, true and correct. Applicant s Signature Producer s Signature (if applicable) Applicant s Name (print) Date MM/DD/YY Producer s Name (print) Date MM/DD/YY Page 8 of /17

16 MANDATORY SIGNATURE SUPPLEMENT TO ALL APPLICATIONS, QUESTIONNAIRES, & ENROLLMENT FORMS THE NOTICES CONTAINED ON THIS SUPPLEMENT APPLY TO ALL UNDERWRITING INFORMATION BEING SUBMITTED TO K&K INSURANCE GROUP, INC., INCLUDING APPLICATIONS, QUESTIONNAIRES AND ENROLLMENT FORMS, FOR THE FOLLOWING PERSON OR ENTITY: Applicant name: Applicable in AL, AR, DC, LA, MD, NM, RI and WV Any person who knowingly (or willfully)* 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. *Applies in MD Only. 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 HI For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. 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, 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 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 MA, NE, and VT 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, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties. 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 MN Any person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. 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. FRAUD APPS (2016/04) I understand that K&K Insurance Group, Inc., for the insuring company, shall be permitted but not obligated to inspect a proposed insured s, or an insured s, property and operations for underwriting purposes at any time. Neither the right to make an underwriting inspection nor the making thereof nor any report thereon shall constitute an undertaking, on behalf of or for the benefit of any insured, or other, to determine or warrant that such property or operations are safe or healthful, or in compliance with any standards, rules or regulations. Underwriting inspections when conducted are for the sole purpose of determining and/or improving the insurability of certain property and operations and not safety. I also understand that an insured is solely responsible for the safety of its facilities and operations and shall not rely upon any underwriting inspections to determine the safety of its facilities or operations and shall not diminish or forego its own safety practices and procedures. I understand that the insurance company in determining whether to provide a quotation for insurance coverage will rely on the information contained in the application and all other information being submitted. I hereby warrant, represent and confirm that, to the best of my knowledge, all information provided is complete, true and correct. I also understand that no insurance will be in effect unless and until the insurance company, or K&K as its agent, provides a quotation offering to provide insurance coverage and the insurance company, or K&K as its agent, receives written notice that the terms and conditions contained in the insurance quotation provided are accepted. APPLICANT S SIGNATURE FRAUD WARNING PRODUCER S SIGNATURE (if applicable) PRINT NAME DATE (MM/DD/YY) PRINT NAME DATE (MM/DD/YY) /16