TRAVEL AGENTS AND TOUR OPERATORS LIABILITY

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TRAVEL AGENTS AND TOUR OPERATORS LIABILITY INSURANCE POLICY

NEW BUSINESS APPLICATION

Applicant Information

Company/Applicant Name:

Applicant Business Type: Corporation LLC Partnership Sole Proprietorship Individual Other

Street Address:

Address Line 2:

City: State: Zip: Country:

Mailing Address (if different from above):

Mailing Address line 2 (if different from above):

City: State: Zip: Country:

Website Address:

Contact Name: Contact Title:

Phone: Contact Person’s Email Address:

Please answer the following questions. Attach a separate sheet, if necessary.

1. Please indicate the desired Limit:

Per Occurrence/Policy Aggregate

$500,000/$500,000 $2,000,000/$2,000,000 $4,000,000/$4,000,000

$1,000,000/$1,000,000 $3,000,000/$3,000,000 $5,000,000/$5,000,000

2. Please indicate the desired Deductible:

Per Occurrence

$500 $2,500 $10,000

$1,000 $5,000 Other:

3. List all other entities to be insured, including Trade Names (if none, please indicate N/A)

Name of Entity Address (if different) Date Established Business Type

4. List all branch locations including mailing address if different from above (if none, please indicate N/A)

Name of Branch Address (if different)

ARCH INSURANCE COMPANY

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5. What year was your company established?

6. H

ow long has your senior management been in the travel/tour industry (new applicants only)? years

7. Does the applicant have an ownership interest in any other businesses? Yes No

If Yes, please describe

8. D

uring the past 12 months:

A. Has there been a change in ownership, management and/or a name change? Yes No

If Yes, please describe:

B. Any change in applicant’s operations? Yes No

If Yes, please describe:

9. G

ross Sales Volume (NOT COMMISSIONS/REVENUE/PROFITS/FEES)

A. Estimate of Total Gross Sales from your travel, tour, and/or meeting planning business for the next 12 months

B. Actual Total Gross Sales for your travel, tour, and/or meeting planning business for last 12 months

10. Check all applicable categories and state their percentage of Total Gross Sales Volume (The total of A.– F. should be 100%)

%Travel Agency

a. % Leisure Travel The total of a. and b. should be 100%

b. % Corporate Travel

% Host Agency

% Tour Operator

% Meeting Planner

% DMC/Receptive

% Other Please describe:

11. Please complete the following:

A. Number of Employees FT PT

B. Number of Independent Contractors FT PT

C. Number of Active Owners

D. Total Number of Persons Booking Travel

E. Do any staff members have Travel Industry designations or certifications? If so, please check all that apply:

12. Does your company sell travel services to customers residing outside of the United States? Yes No, if Yes

A. In what countries do these customers reside?

B. W

hat percentage of your Annual Gross Sales is derived from these international customers? %

C. Is the travel sold to these customers inbound to the United States? Yes No

If No to 12.C, what are the travel destinations sold to these customers?

13. Does the applicant utilize terms and conditions with disclaimers in promotional materials or brochures, on invoices or

itineraries, on a website, or any other location?

Yes No

14. If you are selling travel in the name of your host agency do you utilize and provide their terms and conditions to your

customers?

Yes No NA List host agency, if applicable:

15. Does the applicant currently offer or recommend Travel Insurance? Yes No

16. List all of the travel industry organizations or entities in which the applicant holds an appointment, a membership and/or

franchise ownership:

Certified Travel Counsellor(CTC)

Certified Tour Professional(CTP)

Certified Student Travel

Professional (CSTP)

Master Cruise Counsellor(MCC)

Certified Meeting Professional (CMP)

Other

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17. If new to Arch, has any prior insurance been issued to the applicant at any time? Yes No NA

18. If Yes, please provide:

A. Insurance Company Name: B. Expiration Date:

C. Limit: D. Premium:

19. If new to Arch, does the applicant have knowledge or information of any occurrence, situation, act, error, or omission which

might give rise to a claim or has already resulted in a claim?

Yes No

If Yes, please describe (attach separate sheet if necessary):

20. Certificates of Insurance – Complete the following for all certificates of insurance requested:

Name of

Requestor

Address COI

Only

Additional

Insured

Primary and

Non-

contributory*

Waiver of

Subrogation*

30-Day

Notice of

Cancellation

Relationship

to Applicant**

*For requests including primary and non-contributory language and/or a waiver a subrogation, please attach a copy of

the contract stating these requirements.

** Use the following to indicate the relationship to the Applicant: (C) Client; (S) Supplier/Vendor; (L) Landlord; (VU)

Venue; (SCH) School; (M) Municipality; (O) Other

FOR ALL APPLICANTS THAT OPERATE, PACKAGE, OR PRIVATE-LABEL THEIR OWN TOURS OR PLAN MEETINGS A TOUR

OPERATOR AND MEETING PLANNER SUPPLEMENTAL QUESTIONNAIRE WILL BE REQUIRED.

REPRESENTATIONS:

The signer of this application acknowledges and understands that the information

provided in this

Application is material to the Insurer’s decision to provide the requested insurance and is relied on by the

Insurer in providing such insurance. The signer of this application represents that the information

provided in this Application is true and correct in all matters.

The signer of this Application further represents that any changes in matters inquired about in this

Application occurring prior to the effective date of coverage, which render the information provided

herein untrue, in

correct or inaccurate in any way will be reported to the Program Administrator

immediately in writing. The Program Administrator reserves the right to modify or withdraw any quote or

binder issued if such changes are material to the insurability or premium charged, based on the Insurer’s

underwriting guides. The Program Administrator

is hereby authorized, but not required, to make any

investigation and inquiry in connection with the information, statements and disclosures provided in this

Application. The decision of the Program Administrator

not to make or to limit any investigation or

inquiry shall not be deemed a waiver of any rights by the Insurer and shall not estop the Insurer from

relying on any statement in this Application in the event the Policy is

issued. It is agreed that this

Application shall be the basis of the contract should a policy be issued.

TICE: ANY PERSON WHO, KNOWINGLY OR WITH INTENT TO DEFRAUD OR TO FACILITATE A

FRAUD AGAINST ANY INSURANCE COMPANY OR OTHER PERSON, SUBMITS AN APPLICATION OR

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FILES A CLAIM FOR INSURANCE CONTAINING FALSE, DECEPTIVE OR MISLEADING INFORMATION

MAY BE GUILTY OF INSURANCE FRAUD.

THE COMPLETION OF THIS APPLICATION OR THE ATTACHED SUPPLEMENTS, OR TENDERING OF

PREMIUM DOES NOT BIND COVERAGE. THIS APPLICATIO

N IS SUBJECT TO THE UNDERWRITING

RULES OF THE INSURANCE COMPANY. APPLICANT’S ACCEPTANCE OF THE INSURER’S QUOTATION

IS REQUIRED PRIOR TO BINDING COVERAGE AND POLICY ISSUANCE.

Must be signed by a person who has the authority to sign on behalf of and to bind the Applicant, all firms

and individuals requesting insurance through this application.

NOTICE TO ALABAMA APPLICANTS:

Any person who knowingly presents a false or fraudulent claim for

payment of a loss or benefit, or who knowingly presents false information in an application for insurance is guilty

of a crime and may be subject to restitution or confinement in prison, or any combination thereof.

NOTICE TO ARKANSAS, NEW MEXICO, RHODE ISLAND AND WEST VIRGINIA 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 Agencies.

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 KANSAS APPLICANTS: 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 statement as part of, or in support of, an application for the issuance of, or the rating of an

insurance policy for personal or commer

cial 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.

NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with the intent to defraud any Insurance

Company or other person files an application for insur

ance 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 and with intent to deceive, presents a false

or fraudulent claim for payment of a loss or benefit, or knowingly and with intent to deceive, presents false

information, that is material to the risk, in an application for insurance is guilty of a crime and may be subject to

fines and confinement in prison.

NOTICE TO MAINE, TENNESSEE, VIRGINIA AND WASHINGTON 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.

NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent

claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for

insurance is guilty of a crime and may be subject to fines and confinement in prison.

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NOTICE TO MINNESOTA APPLICANTS:

A person who files a claim with intent to defraud or helps commit a

fraud against an insurer is guilty of 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 claims 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

NOTICE TO OREGON APPLICANTS: Any person who, knowingly and with intent to defraud or facilitate a fraud

against any insurance company or other person, submits an application, or files a claim for insurance containing

any false, deceptive, or misleading material information may be 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, i

nformation concerning any fact material

thereto, commits a fraudulent insurance act, which is a crime and subjects such person

to criminal and civil

penalties.

MUST BE SIGNED AND DATED BY OWNER, PARTNER OR SENIOR OFFICER OF THE FIRM APPLYING FOR COVERAGE

Signature of Owner, Partner or Senior Officer

Title

Date

/ /

If your state requires that we have information regarding your Authorized Retail Agent or Broker,

please provide below.

Producer Name:

Address:

City: State: Zip Code:

For more information, contact:

1.800.803.1213

fax 516.294.1821

[email protected]

AonTravPro.com

Aon Travel Professionals Liability Insurance | 900 Stewart Avenue, Garden City, NY 11530