Mobile Home Parks And Campgrounds Program Supplemental Application Page 2
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24. Other operations (continued):
θ
θ
Streets and Roads
Ice skating
θ
Number of miles:
Golf course
_______________________________
θ
θ
Swimming Pool
Recreational equipment rental
(snowmobiles, etc.)
Number Indoor:
_________________________________
Describe:
________________________________________
Number Outdoor:
_______________________________
θ
θ
θ
Ski lifts/tows
in-ground
above-ground
θ
LPG sales and/or equipment maintenance
Diving boards/slides/diving plat-
θ
q No
forms? .......................................q Yes
Waterworks and/or sewage treatment/disposal
facilities
Diving board/slide height:
ft.
_____________________
θ
Facility built on former landfill or dump
q No
Swimming rules posted? ............q Yes
θ
Wilderness or primitive camping available
If an outdoor pool, is it fenced
q No
with a self-latching gate?............q Yes
Life-safety equipment available
q No
at pool side? ..............................q Yes
Certified
lifeguard
available
q No
when swimming is allowed? .......q Yes
5. Describe any additional recreational facilities or operations conducted by you or others on the premises:
________________________________________________________________________________________________________________________
APPLICABLE IN THE STATE OF NEW YORK:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for in-
surance or statement of claim containing any materially false information, or conceals for the purpose of misleading, in-
formation 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.
FRAUD WARNING:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for in-
surance or statement of claim containing any materially false information or conceals for the purpose of misleading, infor-
mation concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such
person to criminal and civil penalties.
____________________________________________________________________
___________________________________
PRODUCER’S SIGNATURE:
DATE:
_____________________________________________________________________
___________________________________
APPLICANT’S SIGNATURE:
DATE:
____________________________________________________________
AGENT NAME:
AGENT LICENSE NUMBER:
___________________________
(Applicable to Florida Agents Only.)
Page 2 of 2
GLS-APP-38s (3-02)
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