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Kansas Property Insurance Fraud - Excel

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					                      MT HAWLEY INSURANCE COMPANY SPORTS TRAINING CENTER
                                    ELIGIBILITY QUESTIONNAIRE

                                             QUESTIONS                                            Yes or No
Is Property and Liability Insurance Coverage Currently In Effect?                                   Yes / No
Is Workers Compensation Insurance Coverage Currently In Effect?                                     Yes / No
Has Risk Been Previously Cancelled or Had a Lapse in Coverage?                                      Yes / No
Is Any Property Currently Vacant, Partially Vacant, Unoccupied or Closed For Business?              Yes / No
Is the Risk in the Course of Construction or Major Renovation?                                      Yes / No
Is the Risk Located in a Protection Class 9 or 10 Town?                                             Yes / No
Is RiskMeter Score Above 275?                                                                       Yes / No
Is Management an Extra Innings Franchise Owner?                                                     Yes / No
Does the Owner Have Three Years of Ownership or Five years of Management Experience in
                                                                                                    Yes / No
this Industry?
Does the Risk Have a Current Financial Statement?                                                   Yes / No
Has Management Been Involved in any Bankruptcies, Financial Reorganizations, or Liens in
                                                                                                    Yes / No
the Past 3 Years?
Are Criminal Background Checks Performed on All Management and Those Staff Members
                                                                                                    Yes / No
That Have Any Interaction with Customers?
Has Management Been Involved in a Misdemeanor, a Felony (Other Than a Minor Traffic
                                                                                                    Yes / No
Violation) or Any Criminal Activity?
Has Management Been Involved in Any Lawsuits or Legal Action, Either as a Plaintiff or
                                                                                                    Yes / No
Defendant?
Are Ownership and Management Active in Day to Day Operations?                                       Yes / No
Is Risk Within 1 (One) Mile of the Ocean or Gulf in the Following States, Inclusive of Barrier
                                                                                                    Yes / No
Islands? VA, NC, SC, GA, FL, AL, MS, LA or TX
Is the Electrical System Connected to Circuit Breakers?                                             Yes / No
Do All Structures Contain Battery Operated Smoke Detectors?                                         Yes / No
Is Any Building Greater than 30 Years of Age?                                                       Yes / No
If Greater Than 15 Years Old, Have Electric, Plumbing, Heating and Roof Upgrades Been
                                                                                                    Yes / No
Performed in the Past 10 Years?
Do Any Structures Have More Than 2 Stories?                                                         Yes / No
Is There Any Cooking Done on the Premises?                                                          Yes / No
Are there Day Care or Playgrounds on the Premise?                                                   Yes / No
Are There Any Security Guards on the Premises?                                                      Yes / No
Are There Metal Detectors on the Premises?                                                          Yes / No
Is the Risk Open 24 Hours?                                                                          Yes / No
Does the risk close after 2:00AM on any day of the week? (2:30 in OR)                               Yes / No




    60be700f-4d68-49ee-a78c-5c7052b81e37.xls - EligibilityPage 1 of 6                       Ed. Date 11/23/05
                                          MT HAWLEY INSURANCE COMPANY GENERAL APPLICATION


                                                                              ePAK SUBMISSION
                                                                       GENERAL INFORMATION
Name Insured:                                                              Today's Date:                                   November 15, 2010
DBA:                                                                       Effective Date:
Business Type:            Corp / LLC / Partnership / Individual / Other    Expiration Date:                                December 30, 1900
Mail Address:                                                                   Agent or Producer Name:
City:                                                                           Agency/Sub-Producer Name:
State:                                                                          Agent's Phone No.:
Zip Code:                                                                       Prior Carrier:
Contact Person:                                                                 Risk 3 Year Loss Ratio:
Telephone Number:                                                               Owner/Manager Name:
Fax Number:                                                                     Owner Operated or Leased:
E-mail Address:                                                                 Years of Management Experience:
Federal ID Number:                                                              Years at This Location:
Risk Web Address:                                                               Hours of Operation:
                                                                               LOSS HISTORY
    SUBMIT DETAIL LOSS HISTORY                Premium           Incurred Losses          Number of Claims                    Previous Carrier
Current Year
1st Prior Year
2nd Prior Year
                                                                   PREMISE / BUILDING INFORMATION
PREMISES NUMBER:                 1                       Total # of Premises:                      Total # of Buildings:
Street Address:                                                                                        City:
State:                                                                     Zip:                    County:                                     PC:
                                                                 Building 1     Building 2   Building 3       Deductible Coinsurance Cause of Loss Valuation
Schedule or Blanket Coverage1 :                                                                                                        Special
Building:                                                                                                                              Special
Improvements & Betterments:                                                                                                            Special
Business Personal Property:                                                                                                            Special
     Theft Deductible (BPP Only, if Special COL)                                                               Property                Special
     Exclude Theft? (BPP Only, if Special COL)                    Yes / No       Yes / No     Yes / No
Business Income:                                                                                                                       Special
     Business Income Monthly Limit Option:                                                                               1/3, 1/4, 1/6
Bldg Ordinance A:                                                 Yes / No       Yes / No     Yes / No
Bldg Ordinance B:
Bldg Ordinance C:
Awnings:
Outdoor Signs:
Property Extension Endorsement                                                      Yes / No
Total Square Footage:
Patio Square Footage (if applicable):
Number of Stories:
     Number Occupied by the Insured:
Construction:
Year Built:                                                           ?               ?               ?
Has the Building Been Updated?                                     Yes / No        Yes / No        Yes / No
     Year HVAC Updated:
     Year Roof Updated:
     Year Electrical Updated:
     Year Plumbing Updated:
Exclude Ordinary Payroll?                                          Yes / No        Yes / No        Yes / No
Is the Building Fully Sprinklered?                                 Yes / No        Yes / No        Yes / No
     If Yes, Is Evidence of a Sprinkler Flow Test
                                                                   Yes / No        Yes / No        Yes / No
     Available?
     Contractor Name:
     Most Recent Test Date:
Is There an Active Fire Central Station Alarm with a
                                                                   Yes / No        Yes / No        Yes / No
Valid Certificate Present?
     Do You Warrant the System is Operational in
                                                                   Yes / No        Yes / No        Yes / No
     Return for a Premium Credit?




       60be700f-4d68-49ee-a78c-5c7052b81e37.xls - General App                     Page 2 of 6                                           Ed. Date: 11/23/05
                                             MT HAWLEY INSURANCE COMPANY GENERAL APPLICATION


                                                                          ePAK SUBMISSION
Is There an Active Burglar Central Station Alarm with a            GENERAL INFORMATION
                                                            Yes / No          Yes / No      Yes / No
Valid Certificate Present?
     Do You Warrant the System is Operational in
                                                            Yes / No          Yes / No      Yes / No
     Return for a Premium Credit?
Are Smoke Detectors Installed on the Premises?              Yes / No          Yes / No      Yes / No
     Are They Hardwired or Battery?
Are There Fire Extinguishers on the Premises?               Yes / No          Yes / No      Yes / No
     How Frequently Are They Inspected?
Distance to Nearest Fire Department?
Distance to Nearest Fire Hydrant?
Roof Type:
Is There a Canopy of the Same Construction Attached
                                                            Yes / No          Yes / No      Yes / No
to the Building?
1
   Blanket only available between Bldg, I&B and BPP at each location; it is NOT available between locations.
                                                                CATASTROPHE EXPOSURES
                           WIND                                    Premise 1                      Premise 2                                   Premise 3
Is Wind/Hail Excluded?                                              Yes / No                      Yes / No                                    Yes / No
What is the Distance From Coastal Water?
Wind Deductible (if different from Property Deductible)              Property                      Property                                    Property
                                              INLAND MARINE EXPOSURES                                                                         YES / NO
                                                                   Premise 1                      Premise 2                                   Premise 3
Is Any Equipment Rented, Loaned To/From Others
                                                                    Yes / No                      Yes / No                                    Yes / No
With or Without Operators?
Is Applicant Operating Equipment Not Listed on the
                                                                    Yes / No                      Yes / No                                    Yes / No
Equipment Schedule?
Is Any of the Property Used Underground?                            Yes / No                      Yes / No                                    Yes / No
Where is Equipment Stored After Hours?
                                                                                                 Coverage Limits
EDP                                                            Select Limit Options          Select Limit Options                        Select Limit Options
Bailees Floater Limit
Equipment Floater Limit
                                              CRIME / FIDELITY EXPOSURES                                                                      YES / NO
                                                                   Premise 1                      Premise 2                                   Premise 3
Number of Employees?
Number of Deposits Per Week?
Are There Any Prior Crime/Fidelity Losses?                          Yes / No                      Yes / No                                    Yes / No
                                                                                                 Coverage Limits
Employee Theft            Deductible:                          Select Limit Options
Forgery or Alteration                                          Select Limit Options
Inside – Robbery          Deductible:                          Select Limit Options
Inside – Theft                                                 Select Limit Options
Outside – Premises                                             Select Limit Options
Computer Fraud                                                 Select Limit Options
Counterfeit Currency                                           Select Limit Options
                                                                   LIABILITY COVERAGES
Each Occurrence/ General Aggregate Limit                                                        Insert Limit Options
Products/Completed Operations Aggregate Limit                                                   Insert Limit Options
Fire Damage Limit                                                                                     $50,000
Medical Expense                                                                                     EXCLUDED
Bodily Injury Deductible                                                                    Select Deductible Options
Property Damage Deductible                                                                  Select Deductible Options
Sports Participant Coverage                                                                     Insert Limit Options
Abuse or Molestation Coverage                                                                   Insert Limit Options
Hired and Non Owned Auto 1                                                                           Yes / No
Employee Benefits E & O Coverage                                                                     Yes / No
Employers Liability Stop Gap Coverage                                                                Yes / No
1
    Hired & Non-Owned Auto coverage is NOT available if Primary Auto coverage is in force. Must answer question relating to Primary Auto or
    coverage will NOT be granted.




          60be700f-4d68-49ee-a78c-5c7052b81e37.xls - General App                Page 3 of 6                                                     Ed. Date: 11/23/05
                                          MT HAWLEY INSURANCE COMPANY GENERAL APPLICATION


                                                                     ePAK SUBMISSION
                                                           GENERAL INFORMATION
                          MORTGAGEE / LOSS PAYEE / ADDITIONAL INSURED INFORMATION                                               YES / NO
                            Mortgagee                      Loss Payee/Additional Insured                          Loss Payee/Additional Insured
Name
Address
City
State
Zip
Location
Relation
                                                                  WARRANTIES AND NOTICES
NOTICE:
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE
CONTAINING ANY MATERIAL 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 (IN NEW YORK) CIVIL PENALTIES.
RETAIL AGENT WARRANTY:
I HEREBY WARRANT AND CERTIFY THAT ALL INFORMATION CONTAINED IN THIS APPLICATION IS CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND
BELIEF, THAT THIS APPLICATION WAS COMPLETED AND PERSONALLY SIGNED BY THE APPLICANT AND THAT A COMPLETED COPY HEREOF HAS BEEN GIVEN TO
THE APPLICANT.


RETAIL AGENT SIGNATURE: ________________________________________________________________________________________________________
PRINT NAME: ______________________________________________________________________________________________________________________________
DATE: ________________________________________________________________________________________________________________________

INSURED WARRANTY:
I HEREBY APPLY FOR A POLICY OF INSURANCE AS SET FORTH IN THE APPLICATION AND I CERTIFY THAT ALL THE INFORMATION PROVIDED BY ME IN THIS
APPLICATION IS TRUE AND COMPLETE. I UNDERSTAND THAT ANY POLICY WHICH MAY BE ISSUED BY THE COMPANY WILL BE ISSUED ON THE BASIS OF AND IN
RELIANCE UPON MY STATEMENTS IN THIS APPLICATION. I AGREE THAT SUCH POLICY SHALL BE NULL AND VOID IF ANY SUCH STATEMENTS ARE FALSE,
MISLEADING OR INCOMPLETE.
NOTICE TO FLORIDA APPLICANTS: “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.


NOTICE TO KENTUCKY APPLICANTS: “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.”

NOTICE TO NEW JERSEY APPLICANTS: “ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY
IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.”

NOTICE TO NEW YORK APPLICANTS: “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 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 $5,000.00 AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.”

NOTICE TO OHIO APPLICANTS: “ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS
AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.”

NOTICE TO PENNSYLVANIA APPLICANTS: “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.”

INSURED SIGNATURE: ____________________________________________________________________________________________________________
PRINT NAME: ______________________________________________________________________________________________________________________________
TITLE: ______________________________________________________________________________________________________________________________
DATE: _________________________________________________________________________________________________________________________

                                               BOTH THE INSURED AND RETAIL AGENT SIGNATURE LINES MUST BE SIGNED




       60be700f-4d68-49ee-a78c-5c7052b81e37.xls - General App              Page 4 of 6                                             Ed. Date: 11/23/05
                                                  MT HAWLEY INSURANCE COMPANY
                                         SPORTS TRAINING CENTER SUPPLEMENTAL APPLICATION

                                                                 UNDERWRITING INFORMATION
                                                                Sports Training Center Submission
                                                                        RISK DATA
Is This a New Venture?                                                                                                                   Yes / No
Do All Instructors and Employees Have a Current, Favorable Background Check?                                                             Yes / No
Has Any Instructor or Employee Been Involved in a Misdemeanor, a Felony (Other Than a Minor Traffic Violation) or Any
                                                                                                                                         Yes / No
Criminal Activity?
Have All Instructors and Employees Been Properly Trained in the Proper Techniques of the Training Equipment Used?                        Yes / No
Is the Building a Free Standing Structure?                                                                                               Yes / No
Is Risk Located in a Shopping Center Strip Mall?                                                                                         Yes / No
     Are There Fire Walls to Create a Separate Fire Division for Sports Training Center?                                                 Yes / No
List Adjoining Property Exposures:
Are There Lightning Rods on Buildings?                                                                                                   Yes / No
Is There Video Surveillance in Common Areas?                                                                                             Yes / No
Are There Vending Machines on the Premises?                                                                                              Yes / No
What is the Average Age of the Clientele?
Is There Food Service on the Premises?                                                                                                   Yes / No
Are Fire Extinguishers Present and Easily Accessible?                                                                                    Yes / No
    Do All Extinguishers Meet Current NFPA Standards?                                                                                    Yes / No
Are All Electrical Outlets GFCI?                                                                                                         Yes / No
Are Surge Protectors in Place for All Computerized Systems? (Bldg Ops and Telephone)                                                     Yes / No
Are Smoking Areas Equipped with Adequate Number of Self Closing, Fire Resistant Receptacles?                                             Yes / No
                                                 BATTING/PITCHING CAGES                                                                  YES / NO
Number of Training Machines?
Are Machines Regularly Inspected by the Manufacturer or Manufacturer's Representative?                                                  Yes   /   No
Is Equipment NRTL Listed?                                                                                                               Yes   /   No
If Power Transformers are Used, are they Located Outside and Properly Grounded?                                                         Yes   /   No
Is the Use of Batting Helmets in Cages Strictly Enforced?                                                                               Yes   /   No
Are Baseballs/Softballs Regulary Picked up to Control the Tripping Hazard?                                                              Yes   /   No
Are Signs Posted Warning Participants That "Helmets Must be Worn Within All Batting Cages" and "Absolutely No Swinging of
                                                                                                                                        Yes / No
Bats Outside Batting Tunnels" in the Sports Training Center?
Are Food or Drink Allowed in the Sports Training Area?                                                                                  Yes / No
                                          ATHLETIC PARTICIPANT EXPOSURES                                                                 YES / NO
Does Insured Require a Medical Release Form be Signed For Each Underage Participant by a Parent/Guardian?                                Yes / No
Are Parents/Guardians of Underage Participants Required to Provide a Telephone Contact Number During Sports Clinic
                                                                                                                                         Yes / No
Hours?
Are All Participants Required to Wear Proper Athletic Safety Equipment?                                                                  Yes / No
Is the Sports Training Center's Discipline Policy Posted?                                                                                Yes / No
Does Each Participant Have Prearranged Transportation To and From the Facility?                                                          Yes / No
Is Insured's Instructor Responsible for Both Instruction and Supervision?                                                                Yes / No
Describe All Activities Available for Participants:
Does Insured Offer Training Camp for Developmentally and/or Physically Disabled Individuals?                                              Yes / No
Does Insured Use Off Site Premises for Instruction?                                                                                       Yes / No
    If so, Is the Off Site Premises:                                                                                                  Owned / Leased
    If Leased, is the Insured Responsible for the Site 365 Days Each Year?                                                                Yes / No
Any Off Premises Sites That Require to be Added as an Additional Insured?                                                                 Yes / No
Annual Number of Sports Camp Participants                                                  Annual Number of Training Center Visits:




         60be700f-4d68-49ee-a78c-5c7052b81e37.xls - Supplemental App         Page 5 of 6                                               Ed. Date 11/15/05
                                                     MT HAWLEY INSURANCE COMPANY
                                            SPORTS TRAINING CENTER SUPPLEMENTAL APPLICATION

                                                                     UNDERWRITING INFORMATION
                                                                    Sports Training Center Submission
                                                                   RISK DATA
                                           ABUSE OR MOLESTATION EXPOSURES                                                                       YES / NO
Is Student to Instructor Ratio Greater Than 10:1?                                                                                               Yes / No
What is the Total Number of Instuctors:
What is the Total Number of Employees:
Are Any of the Clinics:                           Day Camps:      Yes / No                                     Overnight Camps:                 Yes / No
    What is the Typical Participant Split:                                      Girls:                                      Boys:
Are All Instructors Properly Screened Including References Checked?                                                                             Yes / No
What is the Instructor's Experience in this Field?
Are All Volunteers Properly Screened, Including References Checked?                                                                             Yes / No
What is the Maximum Number of Campers at Any One Time?
                                                                          LIFE SAFETY
Do All Instructors Have Red Cross or Equivalent Training in First Aid and CPR?                                                                  Yes / No
     Are They Required to Participate in Follow-up Training or Refresher Courses to Keep Abreast of Appropriate Emergency
                                                                                                                                                Yes / No
     Procedures?
Are Emergency Plans Posted in Public Areas?                                                                                                     Yes / No
Is There Emergency Lighting in Corridors, Interior Hallways & Stairs?                                                                           Yes / No
Is There a Written Life Safety Plan?                                                                                                            Yes / No
Are There Any Firearms on the Premises?                                                                                                         Yes / No
Is There an Adequate Number of Fire Exits for a Safe Evacuation in the Event of an Emergency?                                                   Yes / No
Are all Fire Exits Adequately Placed, Lighted and Clearly Visible to All ?                                                                      Yes / No
                                   NON OWNED / HIRED AUTOMOBILE EXPOSURES                                                                       YES / NO
Do Any Employees Operate Any Vehicles on Behalf of the Applicant?                                                                               Yes   /   No
Does Applicant Check MVR's of Every Employee Who Operates a Vehicle on the Applicant's Behalf?                                                  Yes   /   No
Are Any Vehicles Ever Used to Transport Sports Clinic Participants?                                                                             Yes   /   No
Does the Risk Transport Sports Camp Members in Owned, Non-Owned or Hired Vehicles?                                                              Yes   /   No
                                                               SPORTS TRAINING CENTER EXPOSURES
                    EXPOSURE AMOUNT DATA                                      Premise 1                      Premise 2                          Premise 3
Total Number of Pitching/Hitting Machines:
Sports Camps- Avg Number of Daily Camp Participants:
Sporting Goods Shop Gross Sales:
Miscellaneous Receipts:
Lessor's Risk Only Exposure: Type and Square Footage
Owned Parking Lot Square Footage:
Vacant Land (Acres):
Employee Benefits Annual Payroll (Per Location):
Stop Gap Annual Payroll (State Specific):
                                                                2
Does the Insured Have Primary Auto Coverage in Place?

Identify Additional Insured(s), Including the Relationship:
2
    Hired & Non-Owned Auto coverage is NOT available if Primary Auto coverage is in force. Must answer question relating to Primary Auto or
    coverage will NOT be granted.




            60be700f-4d68-49ee-a78c-5c7052b81e37.xls - Supplemental App         Page 6 of 6                                                   Ed. Date 11/15/05

				
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