Frazier Insurance Agency > Hole in One

General Information

Applicant's Name:
Street Address:
City:
State:
Zip:
Phone:
Fax:
E-mail address:

Liability Information

Amount of Coverage Desired:
Coverage dates: -

Attraction Information

Type of Event: Target Round of Play
Name of Course:
Address:
Hole(s) to be covered:
Total length in yards:
Total par:
Number of Holes-in-One on the Covered Hole(s) in the last 5 years:
Number of Amateur Players:
Number of Professional Players:

Affirmation and Signature

FRAUD STATEMENT:

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.

WARRANTY STATEMENT:

The Hole-in-One must occur during official tournament play.
No practice shots shall be permitted and all shots shall be made in the regular round of tournament play.
Two Tournament Committee appointed observers shall be stationed at the selected target hole(s) at all times during the tournament. One at the tee and the other at the green.
The target hole(s) will measure from teeing ground to flagstick no less than the specified yardage. Only one pre-designated hole may be used on the target hole green.
The Hole-in-One must occur by an official registered competitor.
The following documentation will be furnished to the Insurance Company as proof of a Hole-in-One claim:

Attached statements by the two target hole observers (described in #1 above), the successful competitor (ACE-maker), and one playing partner.
A signed and completed scorecard of the ACE-maker (photo copies acceptable).
Certified copy of Tournament Pairing Sheet by the golf course professional or tournament director supervising the tournament.

The policy premium together with a signed or accepted application are the basis of this insurance and must be received or postmarked prior to the start of the tournament.
Any policy issued will be based upon the above information and will be considered as warranties in the policy.
I have read, and am aware of the contents of this application form which will be made a part of the policy if accepted and issued by the Company.

Title:
Name of Applicant:
Signature of Applicant:
Date:

Broker Information

Name of Authorized Agent or Broker:
Name of Agency
Agency Mailing Address:
E-mail:
Phone:
Fax:

Hole in One Application

Please note: