HCC Specialty Underwriters -- Event Weather Application Form

EVENT WEATHER INSURANCE APPLICATION

Please complete the online application form below and then hit the SUBMIT button.

Insured Information (required fields = *)

Insured Name

Address Line 1

Address Line 2

City

State

Zip *

Contact Person

Telephone

Facsimile

E-mail

Event Information

Event Type *

	Event Location		Event Date(s)		Event Hours		Hours of Coverage		Limit Per Day
1.		*		*		*		*		*
	e.g. "Boston, MA, 02134"		e.g. "5/18/04"		e.g. "4:00pm to 8:00pm"		e.g. "5:00pm to 7:00pm"		e.g. "$10,000"
2.
3.
4.

Has the event had weather insurance coverage previously?

Yes No *

If yes, when?

Carrier Used

If Applicable, Please Detail Loss History

Rain

Incremental Accumulation ( click here for more information)


1/100"	1/20"	1/10"	1/5"	1/4"	1/3"	1/2"	3/4"	1"	Other

Dry Hours Definition (click here for more information):
hours out of hours (e.g., 6 hours out of 8 hours)

Alternative Peril Options

Snow

Incremental Accumulation (click here for more information)


1"	2"	3"	4"	5"	6"	Other

Other (please be specific):

Claim Settlement

	Closest National Weather Station, as identified by HCC Specialty Underwriters (no cost) The nearest National weather Service Station can be used for claims verification for the insured event. There is no cost to use this service and it take approximately 5 - 8 days after the event date to obtain this data. The insured should be mindful that these stations record rain, snow, etc as it occurs at the address of the station and not at the event location. Since weather can be location specific based on the movement of a storm and the time that it occurs, it is suggested that if a station is further than 10 miles away for the insured location an alternative to this option is selected.
	WeatherWatch Service (at a cost of $50 per Insured date) more info
	On-Site Independent Weather Observer, to be approved by HCC Specialty Underwriters (approximate cost of $35 per Insured Hour) DOWNLOAD IWO APPLICATION An observer can be secured for claims verification purposes and should be done so by contacting HCC Specialty Underwriters. The cost to secure and observer is generally $35 per hour and based on how far the observer must travel, ancillary costs may also be incurred. All observer costs are the responsibility of the Insured. If the Insured chooses to secure an observer on their own, the observer must be pre qualified by HCCSU.

If an approved independent weather observer is not secured by the Insured, for purposes of claim verification, HCC Specialty Underwriters will designate the closest approved recording station in the terms of the contract. Should the Insured require additonal information regarding an observer, please contact HCC Specialty Underwriters.

Agent/Broker Information
If you are a licensed insurance agent or broker, please provide the following information:

Agency/Brokerage

Agent/Broker Name

Telephone Number

Facsimile

E-mail Address

Web Site Address

Mailing Address:

Address Line 1

Address Line 2

City

State

Zip

Do you have E & O Insurance?

Yes No

Proof of E&O Insurance is required to bind coverage

Is the Agency/Brokerage Licenced?

Yes No

Proof of Licensure is required to bind coverage

NOTICE TO 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 ACT, WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.

NOTICE TO ARKANSAS AND NEW MEXICO APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.

NOTICE TO COLORADO APPLICANTS: 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 AUTHORITIES

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.

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 IN 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 LOUISIANA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.

NOTICE TO MAINE APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.

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 ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.

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 OKLAHOMA APPLICANTS: WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY (365:15-1-10, 36 §3613.1).

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.

NOTICE TO TENNESSEE AND VIRGINIA APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.

Coverage is subject to a completed application, full premium payment a minimum of 7 days prior to coverage inception, and acceptance/approval of HCC Specialty Underwriters.

In addition to any underwriting subjectivities, coverage cannot be bound until the following is received by HCC Specialty Underwriters. If you are unable to provide any of this information, please contact HCCSU immediately.

1. Copies of state non-resident Agency/Corporation and Writing Agent/Broker/Producer licenses in state that Insured is domiciled
2. Copies of state resident Agent/Broker/Producer licenses if different than 1. above.
3. Original, completed Broker/Agency Agreement and W-9 for any non-approved HCC Specialty Underwriters producers.

WEATHER INSURANCE IS PREPAID AND CANNOT BE CANCELLED.

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