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MT HAWLEY INSURANCE COMPANY GENERAL APPLICATION
ePAK SUBMISSION
GENERAL INFORMATION
Name Insured: Today's Date: May 5, 2011
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:
Risk Web Address: Years at This Location:
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
LOCATION/BUILDING INFORMATION
PREMISES NUMBER: 1 Total # of Locations: 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
Actual Loss Sustained (Limited availability): Yes / No
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):
Public Square Footage (including Patio, 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?
ea31e33c-452b-4b15-9989-94a81687ae8b.xls - General App Page 1 of 8 Ed. Date: 11/30/05
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?
Distance to Nearest Fire Department?
Distance to Nearest Fire Hydrant?
Roof Type:
Describe Adjoining Exposures:
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 Equipment Used in Underground Work? 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?
Are There Daily Deposits Made? Yes / No Yes / No Yes / No
Are There Any Prior Crime/Fidelity Losses? Yes / No Yes / No Yes / No
Coverage Limits
Employee Theft Deductible: Select Limit Options Select Limit Options Select Limit Options
Forgery or Alteration Select Limit Options Select Limit Options Select Limit Options
Inside – Robbery Deductible: Select Limit Options Select Limit Options Select Limit Options
Inside – Theft Select Limit Options Select Limit Options Select Limit Options
Outside – Premises Select Limit Options Select Limit Options Select Limit Options
Computer Fraud Select Limit Options Select Limit Options Select Limit Options
Counterfeit Currency Select Limit Options Select Limit Options Select Limit Options
LIABILITY COVERAGES
Each Occurrence/ General Aggregate Limit Select Limit Options
Products/Completed Operations Aggregate Limit Select Limit Options
Fire Damage Limit Select Limit Options
Medical Expense Limit or Exclusion Select Limit Options
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
Liquor Liability Coverage 1 Yes / No
Hired and Non Owned Auto 2 Yes / No
Employee Benefits E & O Coverage Yes / No
Employers Liability Stop Gap Coverage Yes / No
1
Liquor Liability coverage is NOT available in all States. Liquor Liability coverage is NOT available if there are firearms on the premises.
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.
ea31e33c-452b-4b15-9989-94a81687ae8b.xls - General App Page 2 of 8 Ed. Date: 11/30/05
MT HAWLEY INSURANCE COMPANY GENERAL APPLICATION
ePAK SUBMISSION
GENERAL INFORMATION
LIFE SAFETY
Are GFCI Breakers/Outlets Installed? Yes / No
Are There Fire Extinguishers on the Premises? Yes / No
Have They Been Serviced in the Last 12 Months? Yes / No
Are Emergency Plans Posted in Public Areas? Yes / No
Is There Emergency Lighting in Corridors, Interior Hallways & Stairs? Yes / No
Are There Smoke Detectors in All Common Halls and Stairways? Yes / No
Is There a Written Life Safety Plan? Yes / No
Are There Any Firearms on the Premises?1 Yes / No
Is There an Adequate Number of Fire Exits for a Safe Evacuation in the Event of an Emergency (if applicable)? Yes / No
Are all Fire Exits Adequately Placed, Lighted and Clearly Visible to All ? Yes / No
Are Employees Properly Trained in Crowd Control Techniques (if applicable)? Yes / No
1
Liquor Liability coverage is NOT available in all States. Liquor Liability coverage is NOT available if there are firearms on the premises.
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 TH
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
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
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
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, INFORMATI
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, IN
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
INSURED SIGNATURE: ____________________________________________________________________________________________________________
PRINT NAME: ______________________________________________________________________________________________________________________________
TITLE: ______________________________________________________________________________________________________________________________
DATE: _________________________________________________________________________________________________________________________
BOTH THE INSURED AND RETAIL AGENT SIGNATURE LINES MUST BE SIGNED
ea31e33c-452b-4b15-9989-94a81687ae8b.xls - General App Page 3 of 8 Ed. Date: 11/30/05
GOLF COURSE ELIGIBILITY QUESTIONNAIRE
QUESTIONS Yes or No
Is Property and Liability 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
Yes / No
Closed For Business (Other than Seasonal)?
Is the Risk in the Course of Construction or Major Renovation? Yes / No
Does the Owner Have Three Years of Ownership or Three Years of
Yes / No
Management Experience in the Industry?
Have There Been Any Bankruptcies, Financial Reorganizations, or
Yes / No
Liens in the Past 3 Years?
Is Risk Within 1 (One) Mile of the Ocean or Gulf in the Following
States, Inclusive of Barrier Islands? VA, NC, SC, GA, FL, AL, MS, LA Yes / No
or TX
Is the Electrical System Connected to Circuit Breakers? Yes / No
Is Any Building Greater than 20 Years of Age? Yes / No
If Greater Than 20 Years Old, Have Electric, Plumbing, Heating and
Yes / No
Roof Upgrades Been Performed in the Past 15 Years?
Do Any Structures Have More Than 2 Stories? Yes / No
Does Kitchen Have an Automatic Suppression System? Yes / No
Does the Insured Require Sporting Event Coverage? Yes / No
Does the Course Have a Minimum of 9 Holes? Yes / No
Is Facility a Private Country Club? Yes / No
Does the Risk Employ Bouncers, Doormen, or ID Checkers? Yes / No
Does the Restaurant, Bar or Lounge Close After 12:00AM on Any Day
Yes / No
of the Week?
If Alcohol is Served, Is There a Certified Alcohol Server Training Yes / No / Not
Program in Place? Applicable
Are Employees Allowed to Consume Alcohol During Employment
Yes / No
Hours?
Does Risk Allow Any Type of Pyrotechnic Activities On or Off Premises? Yes / No
Does the Risk Provide Valet Parking Service? Yes / No
Does the Risk Have any Owned Vehicles? Yes / No
Does the Risk Have a Daycare Facility, Children-Only Swimming Pools, Yes / No
or Swimming Pools With Any Type of “Slides” or Diving Boards?
Does the Risk Have a Swimming Pool Open to the Public? Yes / No
Does the Risk Have a Playground? Yes / No
Yes / No
Is Snowmobiling, Skiing, or Ice Skating Allowed on the Risk Premises?
Does the Risk Have Apartments or Dwellings For Use by Other Than
Yes / No
the Course Manager?
Are There Any Firearms or Guard Dogs on Premises During or After
Yes / No
Business Hours?
Are There Bars on the Windows? Yes / No
Page
ea31e33c-452b-4b15-9989-94a81687ae8b.xls - Golf Eligibility 4 of 8 Ed. Date: 05/30/06
MT HAWLEY INSURANCE
GOLF COURSE SUPPLEMENTAL APPLICATION
UNDERWRITING INFORMATION
Golf Course Submission
COURSE DATA
Number of Months Course is Open
If < 12 Months - Explain Premises Security When Closed:
How Are Pipes Kept From Freezing?
Type of Course (Mark all that apply) Select Type
Is This Club A “Soft Spike Only” Facility? Yes / No
Is There A Lightning Detection/Notification System? Yes / No
Is The Course Sprinkler System Electronically Controlled? Yes / No
If Yes, Is The Entire System Grounded? Yes / No
How Often Is The System Checked For Property Grounding Ann / Qtr / Semi-Ann / Month
Does This Facility Require All Golfers to Sign a “Hold Harmless” Agreement Which Holds the Course Harmless for Injuries to If Yes, Submit a Copy of the
Themselves and From Injuries the Golfers Cause to Others? Agreement
Explain any Non-Golf Activities Below Such Tennis, Horseback Riding, Ice Skating, Sledding, Snowmobile, ATV, Fireworks, Skeet/Trap Shooting, Babysitting,
Boats, etc. that are Done at Premises (Excl Swimming):
Is Alcohol Consumption Allowed on the Golf Course? Yes / No
Is Any Equipment Rented To Participants? Yes / No
Are There Lightning Rods on Buildings? Yes / No
Are There U.L. Certified Surge Protectors on All Personal Computers, Computerized Systems for the Buildings/Operations,
Yes / No
and Telephone Systems?
Is There Video Surveillance in Common Areas? Yes / No
GOLF FOOD SERVICE EXPOSURES YES / NO
Is There a Restaurant or Food Service on any Part of the Premises? Yes / No
Is It Operated by? Insured / Concession
What is the Seating Capacity?
If Concession, Does Lessee Provide Insured with Certificates of Insurance with Equal to Those Carried by Insured and
Yes / No
Naming Insured as an Additional Insured?
COOKING / KITCHEN EXPOSURES YES / NO
Are There Any Restaurants, Owned or Leased, on the Premises? Yes / No
Is the Restaurant Owned or Leased? Owned / Leased
If Leased, Does the Lessee Provide the Lessor with a Certificate of Insurance? Yes / No
Is There Open or Deep Fat Fry Cooking on Premises? Yes / No
List Number of: Ranges / Deep Fryers / Char Broilers / Flat Grills / Woks:
Is There a High Temperature Limit Control on Deep Fryers? Yes / No
Does the Deep Fat Fryer Have a Minimum of 16" Clearance From Open Flames or Have a Baffle Plate/Splashguard? Yes / No
Are Automatic Fuel Shut Offs Installed? Yes / No
Does the Risk Have a Kitchen Automatic Fire Suppression System? Yes / No
Has the Kitchen Automatic Fire Suppression System Been Serviced in the Last 12 Months? Yes / No
How Frequently Is the Kitchen Automatic Fire Suppression System Cleaned/Inspected? Ann / Qtr / Semi-Ann / Month
Name of Servicing Company for the Kitchen Automatic Fire Suppression System:
Does the Cooking Area Have a Hood and Duct System? Yes / No
Name of Servicing Company for the Hood and Duct System:
Date the Hood and Duct System Was Last Cleaned:
How Frequently Is the Hood and Duct System Cleaned? Ann / Qtr / Semi-Ann / Month
Is the Kitchen Equipped With Fire Extinguishers? Yes / No
Have the Fire Extinguishers Been Serviced in the Last 12 Months? Yes / No
ea31e33c-452b-4b15-9989-94a81687ae8b.xls - Golf Supp Page 5 of 8 Ed. Date 03/08/06
MT HAWLEY INSURANCE
GOLF COURSE SUPPLEMENTAL APPLICATION
UNDERWRITING INFORMATION
Golf Course Submission
COURSE DATA
ALCOHOLIC BEVERAGE EXPOSURES YES / NO
Does Risk Have a Separate Bar Area? Yes / No
What is the Seating Capacity?
What Hours is Liquor Served?
Does the Risk Offer Happy Hour or Discounted Drink Specials? Yes / No
If Yes, What Hours are Usually Designated as "Happy Hour"?
What Days are "Happy Hour" Specials Offered?
Do Any "Happy Hour" Specials Extend Past 9:00PM? Yes / No
Does Establishment Have a Current and Valid Liquor License? Yes / No
Number of Warnings/Citation/Violations in the Past 5 Years
Explain Any Warnings/Citation/Violations Received:
Has Liquor License Ever Been Suspended or Cancelled? Yes / No
If Yes, Please Describe:
Does Applicant Keep an Alcohol Incidents Log Book? Yes / No
Does Applicant Currently Have Liquor Coverage? Yes / No
Select the Type of Alcohol Served: Beer / Liquor / Wine
Describe Who Serves Alcohol if Served By Other Than Insured?
Are Patrons Allowed to Bring in or Store Their Own Alcoholic Beverages (BYOB)? Yes / No
Is Management Notified Prior to "Shutting Off" any Patron? Yes / No
If Alcohol is Sold by Others, are Certificates of Insurance Required Naming Our Insured as an Additional Insured? Yes / No
Are All Servers Over the Legal Drinking Age? Yes / No
Are Signs Visibly Posted Displaying Legal Drinking Age? Yes / No
Are Ride Services Available for Intoxicated Patrons? Yes / No
Are Patrons Under 21 Years of Age Allowed in Bar Area After 10:00PM Yes / No
Does the Insured Sponsor Any Teen Nights or Events Targetted at Patrons Under 21 Years of Age Yes / No
ENTERTAINMENT EXPOSURES YES / NO
What is the Seating Capacity for Entertainment?
What is the Average Age of the Clientele?
Is There Any Live Music Provided? Yes / No
If Yes, Please Select The Type of Music Played:
If 'Other" is Selected as the Type of Music, Please Describe:
Number of Nights per Week Live Music is Available:
Is There a Stage on the Premises? Yes / No
If Yes, Is the Stage Elevated? Yes / No
Is There Any Non-Live Music Provided? Yes / No
If Yes, Please Select the Music Source:
If a DJ is Used, How Many Nights is He/She Present?
If a DJ is Used, Please Describe the Type of Music Played:
Is Any Non-Music Entertainment Provided (i.e. Comedians, Magicians, Poets)? Yes / No
If Yes, Please Describe:
Number of Nights per Week Non-Music Entertainment is Available:
Is a Cover Charge Ever Made for Any Event? Yes / No
Are Any Contests and/or Sporting Events Conducted on the Premises? Yes / No
If Yes, Please Describe:
Are Any Tournaments Conducted on the Premises (i.e. Poker, Darts, etc.)? Yes / No
If Yes, Please Describe:
Are There Dinner Theater Nights Conducted? Yes / No
If Yes, How Frequently Are They Held?
Number of Pool Tables, if any
Number of Video Games, if any (i.e. Video Poker, Arcade Games, etc.)
Number of Table Games, if any (i.e. Shuffle Board, Poker, Foosball, etc.)
Is There a Dance Floor on the Premises? Yes / No Square Footage:
ea31e33c-452b-4b15-9989-94a81687ae8b.xls - Golf Supp Page 6 of 8 Ed. Date 03/08/06
MT HAWLEY INSURANCE
GOLF COURSE SUPPLEMENTAL APPLICATION
UNDERWRITING INFORMATION
Golf Course Submission
GOLF CART EXPOSURES COURSE DATA YES / NO
Number of 3-Wheel Golf Carts:
Number of Golf Carts: Owned: Leased:
If Carts are Leased, Does Lessor Provide Insured with Certificates of Insurance with Equal to Those Carried by Insured and
Yes / No
Naming Insured as an Additional Insured?
Does Insured Require a “Hold Harmless” Agreement be Signed for all Persons Leasing a Golf Cart? If Yes, Submit a Copy
Yes / No
of the Agreement.
Does Club Permit Any Cart Usage by Persons Under 16 Years Old? Yes / No
Does Club Permit Any Cart Usage by Persons Not Licensed to Drive? Yes / No
How Are Carts Secured After Hours?
Does Club Maintain a Storage, Service and Battery Charging Facility? Yes / No
If Yes, Are Electrical Systems Designed For Battery Recharging Operations? Yes / No
SWIMMING POOL EXPOSURES YES / NO
What Hours is the Pool Area(s) Open?
Number of Swimming Pools on the Premises?
Are Pools Indoors, Outdoors or Both?
Have There Been Any Code Violations In The Past 5 Years? Yes / No
Is Adult Supervision Required For Children Under 12 Years Old? Yes / No
Is the Pool(s) Enclosed with Restricted Access? Yes / No
Are the Gates Self-Closing/Self-Latching? Yes / No
Is Pool Covered by Separate Glass or Fiberglass Roof? Yes / No
Number of Life Guard(s) on Duty
What Hours are Life Guards on Duty?
What is the Pool Depth Range? From ___ Feet to ___ Feet
Is All Decking and Walkways Covered in a Non Slip Surface? Yes / No
Are Pool Rules Visibly Posted and Legible in Pool Area? Yes / No
Is Life Saving Equipment Present and Visible? Yes / No
Is Glass Restricted in the Pool Area? Yes / No
SAUNA / HOT TUB EXPOSURES YES / NO
What Hours are the Sauna and/or Hot Tub Area(s) Open?
Are the Sauna and/or Hot Tub Area(s) Enclosed with Restricted Access? Yes / No
Is the Sauna and/or Hot Tub Open to the Public, Guests Only, or Both?
Is Adult Supervision Required For Children Under 12 Years Old? Yes / No
Are Sauna and/or Hot Tub Rules Visibly Posted and Legible in the Sauna and/or Hot Tub Area? Yes / No
PRO SHOP EXPOSURES YES / NO
Is the Pro Shop on the Premises? Yes / No
If Yes, is it Operated By the Insured, Leased to the Golf Pro or Leased to Others?
If Leased To Others, Does Lessee Provide The Insured With Certificates Of Insurance With Limits Equal To Those Carried
Yes / No
By Insured And Naming Insured As Additional Insured?
POLLUTION EXPOSURES YES / NO
Are Herbicides/Pesticides Applied by the Insured's Employees or Independent Contractors?
Is Applicator’s License Up To Date? Yes / No
Are All Chemicals E.P.A. Approved? Yes / No
Where are the Chemicals Stored?
Where are the Chemicals Mixed?
Where are the Chemicals Disposed of?
Is the Chemical Storage Facility Access Restricted? Yes / No
Describe Any Other Operations Conducted In The
Storage Facility:
Describe Storage Facility for Flammable Liquids (Gasoline,
Diesel, Paints, etc)
Are UL Listed Containers Used For Storage and
Dispensing?
Is Electrical System UL Listed For This Facility?
Are There Above or Underground Gasoline or Chemical Storage Tanks on Premises? Yes / No
If Yes, Explain Spill Containment Safeguards:
ea31e33c-452b-4b15-9989-94a81687ae8b.xls - Golf Supp Page 7 of 8 Ed. Date 03/08/06
MT HAWLEY INSURANCE
GOLF COURSE SUPPLEMENTAL APPLICATION
UNDERWRITING INFORMATION
Golf Course Submission
OTHER EXPOSURES COURSE DATA YES / NO
Do Any Employees Operate Any Vehicles on Behalf of the Applicant? Yes / No
GOLF EXPOSURES
Environmental Impairment Sub-limit NONE or $300,000
EXPOSURE AMOUNT DATA Premise 1 Premise 2 Premise 3
Annual Number of 18-Hole Rounds:
Average Cost per 18-Hole Rounds:
Annual Number of 9-Hole Rounds:
Average Cost per 9-Hole Rounds:
Greens Fees (Public/Semi-Private Courses):
Membership Fees:
Guest Greens Fees (Private Courses):
Cart Rentals:
Driving Range Receipts:
Pro Shop Sales (Clubs, Apparel, Balls, etc.):
Total Restaurant and Non-Alcoholic Beverage Receipts:
Total Alcoholic Beverage Receipts:
Wedding or Private Function Receipts:
Miscellaneous Receipts:
Number of Apartments on Premises:
Number of Dwellings on Premises:
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? Yes / No Yes / No Yes / No
Identify Additional Insured, 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.
ea31e33c-452b-4b15-9989-94a81687ae8b.xls - Golf Supp Page 8 of 8 Ed. Date 03/08/06
