Cossio Insurance Agency Fax: PO Box 188 Simpsonville SC 29681

Transcription

1 DIRECTIONS: POLICY RECOMMENDATIONS (Please check any you are interested in) General Liability Accident Medical Earthquake Inland Marine Workers Compensation Commercial Auto EPLI Flood Hired & n-owned Auto Umbrella Abuse/Molestation Cyber Liability Section 1: General Information How did you hear about us? 1. Corporate Name: 2. Trade Name: 3. Mailing Address: County: City: State: Zip: Physical Address: County: City: State: Zip: 4. Contact person: Phone Number: Website: 5. Business Type: Corporation Partnership Individual Governmental Entity Other: 6. Year business was established? # of years under present management: 7. FEIN/SS# 8. Annual Gross Sales: 9. Trade associations which insured belong to: 10. Does applicant have a safety manager on premises at all times the facility is open? If yes, provide name an contact information: 11. Does the applicant have a formal safety training program for employees? Section 2: Premises Information 1. Average annual attendance: 2. Hours & Operations: 3. Actual sales from prior year: 4. Number of employees: Page 1 of 11

2 Section 2: Premises Information (continued) 5. Patron Admission Costs: Adults $ Child $ Discount $ 6. Sales / Receipts: a) Amusements $ b) Beer & liquor sales $ c) Parking $ d) Food & Beverage $ Describe: e) Souvenirs/velties $ Describe: 7. Any medical facilities provided or any employed physicians /nurses? 8. Any storage, treating, discharging, applying, disposing or transporting hazardous materials? 9. Any operations sold, acquired or discontinued in the last 5 years? 10. Machinery, equipment or attractions rented or sold to others? 12. Is there a swimming pool on premises? 13. Are all swimming pools and spas compliant with Virginia Graeme Baker Pool and Spa Safety Act? If no, provide time table and action plan: 14. Are there any water hazards or unfenced bodies of water on your premises? 15. Any special events scheduled throughout the year? 16. Does the applicant own or lease the facility? Own Lease If leased provide a copy of the agreement. If leased, who is responsible for the parking areas? Owner Insured Please provide the following information concerning your parking areas: Do you have Valet Parking? Does your parking area have a hard, smooth surface? If open after dark, are your parking areas lighted? Does security patrol your parking areas? If leased, who is responsible for building maintenance? Owner Insured 17. Does applicant own any other commercial property? If yes, please explain. 18. Any structural alterations contemplated? 19. Are any of the insureds locations within 1/2 mile of a military base, defense contractor, major utility, known US landmark, major sports stadium, or a major amusement park? If yes, please explain: 20. Are any services subcontracted? 21. Do you have any tenants? Page 2 of 11

3 Section 2: Premises Information (continued) 22. Distance to nearest hospital? 23. Central station burglar alarm? 24. Surveillance cameras? 25. Does the Applicant have Automated External Defibrillator(s) (AED)? If yes, are staff members trained to use it? Is there an emergency back-up power source for lights and communications? Please describe: 26. Describe the medical response system in place: 27. Aid and CPR? 28. Does the applicant have an emergency evacuation plan? (If yes, attach copy) 29. Are parking lots well lit? 30. Are all curbs, steps, and ledges highlighted? 31. Does your facility comply with current standards set by the Americans with Disabilities Act? 32. Patrolled by security? Describe security (armed/unarmed): Is security present during open hours? Closed hours? 33. Does the applicant provide live entertainment? If yes, describe the type and how often: 34. Do you maintain grandstands? If yes, are any over 15 years old? Seating capacity: Construction: 35. Are there any live animals? Are participants monitored at all times? Are any tasks physical by nature that could potentially cause injury? If yes, please explain Section 3: Operations - CHILDCARE/CHILD DROP-OFF/LOCK-INS N/A 1. Describe the programs for which you allow minor children to be dropped off and supervised by employees: 2. What is the average daily attendance of children dropped off/left in your care? Page 3 of 11

4 Section 3: Operations - CHILDCARE/CHILD DROP-OFF/LOCK-INS (continued) 3. What is the maximum hours per day that a child may be in your care? 4. What is the ratio of attendants to children who are left in your care? 5. What is the minimum age of childcare staff? of children? 6. Do you perform background checks on all staff who are onsite with children who are dropped off and left in your care? 7. What system do you use for checking in and out the children as they arrive & depart? 8. Do you comply with state & local requirements for having minor children in your care? Section 4: ABUSE AND MOLESTATION N/A 1. Does the Applicant s current insurance program include Abuse and Molestation coverage? whether the individual has ever been convicted of any crime, including sex-related or child abuse related or child abuse related offenses, before an offer of employment is made? 3. Does the Applicant verify employment references for employees and volunteers? 4. Does the Applicant conduct personal interviews? Are employment applications required for positions? 5. Are formal written procedures in place for hiring? (If yes, attach a copy) 6. Is there written supervision plan that monitors staff in day-to-day relationships with clients, both off and on the premises? (If yes, attach a copy) 7. Does the applicant have a written crisis plan for dealing with employees, volunteers, victims, parents, authorities and the media if you have an incident of abuse? If yes, attach 8. Have any incidents resulted in an allegation of sexual abuse? If yes, was the case settled? Was the case taken to trial? Amount paid for damages to the victim: $ 9. Does the Applicant s state allow criminal background checks? If yes, does the applicant run criminal checks prior to hire for: Employees Volunteers Both 10. Identify staff status (check all that apply): Employees Volunteers Parent-volunteers Are all staff members age 21 years or older? Page 4 of 11

5 Section 5: LIQUOR N/A 1. Is liquor license in Applicant s name? If no, what is the name on the license and their relationship to the Applicant: Liquor license number: Class of license: 2. Is the liquor service sub-contracted to a third party? If yes, provide limits of liability maintained by the sub-contractor: Is applicant listed as additional insured under sub-contractors liquor liability coverage? Is contingent liquor liability coverage requested by insured? 3. Has the applicant s liquor license ever been revoked or suspended? If yes, explain: 4. Has the applicant incurred claims for liquor liability during the last three (3) years? If yes, explain: 5. Has any insurer canceled or non-renewed coverage during the last three (3) years? If yes, explain: If yes, explain: 7. Type of beverages sold: 8. Are patrons allowed to carry alcoholic beverages onto the premises? If yes, what type: 9. Does the applicant exercise the right to search and seizure contraband items? If yes, how does applicant notify the public of this: 10. Does the applicant maintain security personnel at entry check point? If yes, what type: 11. Are the alcohol sales and consumption contained within one foxed site, or are booths / stands located throughout the event site? 12. Numbers of server used? Are they professional servers? Explain: Are they volunteer servers? Explain: 13. Do the servers receive any type of alcohol awareness training? If yes, describe: 14. Median age of liquor customers: and over Page 5 of 11

6 Section 5: LIQUOR (continued) 15. Are minors allowed to enter the location where alcohol is being served? If yes, how is underage consumption of alcohol prevented: 16. Explain how ID s are checked: 18. Are rules and regulations clearly displayed for patrons viewing? 19. Is there a limit place on the quantity of alcoholic beverages purchased at one time? If yes, explain: 20. Is the parking area patrolled to prevent intoxicated drivers from leaving the premises? Explain: 21. Is there any type of designated driver program? Explain: 22. Do you stop serving at least one hour prior to closing? Section 6: HIRED & NON-OWNED AUTO N/A 1. Does the applicant have any owned automobiles? Do you have a Business Auto Policy for owned autos? 2. Does the applicant allow employees to use their own personal vehicles for business purposes? If yes, how many employees use their own personal vehicles? If yes, how often? Daily Weekly Monthly Other: 3. Does the applicant obtain Motor Vehicle Reports? If yes, how often? Annually Every other year Other: carry minimum personal auto limits? If yes, what minimum limits are required? 5. Provide the approximate cost of hire for all hired/leased autos during the policy period: 6. Is hired auto physical damage required? If yes, what is the maximum value of hired vehicle that the applicant would like insured? $ 7. During the last 3 yrs have you leased, borrowed or hired any vehicles for your business? 8. If you anticipate some usage this year, what type of vehicles (trucks, buses, cars) do you hire, lease and/or borrow? (Explain and identify) Page 6 of 11

7 Section 7: WINTER WEAR FREEZE-UP PROTECTION This section must be completed by all risks that have a location in one of the following states: AR, CT, DC, DE, GA, IL, IN, KY, ME, MD, MA, MI, MO, NH, NY, NJ, NC, OH, PA, RI, SC, TN, TX, VT, VA, WV, WI 1. Fire Protection and Testing i. If yes, approximately what percentage (%) of the building is sprinklered? ii. If yes, what type of sprinkler system is installed? Wet-Pipe Dry-Pipe Both iii. If yes, when possible, is the sprinkler piping primarily run within the 45 degree F minimum temperature? N/A If no, please describe freeze prevention measures (e.g. temperature monitoring, heat trace, full insulation on piping or roof): months & includes a formal winterization review? N/A v. If yes, are the alarms tied to a 24 hour UL listed monitoring company? N/A 2. Emergency Water Response (domestic and AS water lines) a. Are water shutoff valves (domestic and AS water lines) marked and readily accessible? N/A b. Are water shutoff valves exercised (closed and reopened) at least annually? N/A hours? N/A 3. Automatic Water Shutoff Devices f? N/A 4. Unused/Vacant spaces a. Does applicant have a formal process to turn off and drain domestic water lines for these spaces? N/A 5. Unheated Areas (attics, crawl spaces, exterior wall joists) a. Are all domestic water lines located in areas heated to at least 45 degrees F? N/A i. If no, please describe freeze prevention measures (e.g. temperature monitoring, heat trace, full insulation): Page 7 of 11

8 ESCAPE ROOM APPLICATION Section 8: PROPERTY INFORMATION Please complete once for each location if you are interested in a quote for your property. 1. Location Address City: 2. Construction of Building: Other (Describe) Facility Sprinklered?: Burglar Alarm?: Owner: 3. Property Values Fire Resitive Mas.n/Comb Joisted Masonry Frame Include in contents: All Equipment, Furniture & Fixtures, EDP, Improvements and Betterments Safe? 4. Additional Interests #1 State: If, Manufacturer: Zip: Fire Alarm? Central Station Alarm Local Gong Type: Central Station Alarm Local Gong Tenant: Crime Exposures, On Premises: Maximum Daily Cash $ Amount Overnight $ Address: Building $ Contents $ Loss of Income $ Desired Crime Limit: Landlord Loss Payee Mortgagee Name: City: State: Zip: 5. Additional Interests #2 Landlord Address: City: Loss Payee Mortgage Name: State: Zip: 6. Carrier Information Insurance Co. Name: Date Policy Expires: Annual Property Premium: $ Deductible: $ 7. Property Claims Information: (Please complete for each year) 2015 Number of Claims: Amount Paid: 2014 Number of Claims: Amount Paid: 2013 Number of Claims: Amount Paid: 2012 Number of Claims: Amount Paid: 2011 Number of Claims: Amount Paid: Building Improvements: Wiring Year: Roofing Year: Plumbing Year: Heating Year: 8. Distance to nearest fire station: Distance to nearest fire hydrant: Number of stories: Page 8 of 11

9 ESCAPE ROOM APPLICATION Section 9: LIABILITY CLAIMS INFORMATION* Indicate below, the # of Claims and Amount Incurred (paid + reserved) in each of the last 5 years: Year Number of Claims Total Incurred Amount *te: please forward current loss runs from your carrier, along with this application. Section 10: ADDITIONAL ACTIVITIES N/A Do you have any of the following? Cooking Facilities Rides/Attractions Arcades Bumper Boats Inflatables Bumper Cars Batting Cages Kiddie Rides Go Karts Inflatable Rentals Miniature Golf Driving Ranges Paintball / Airsoft / Laser Tag Mobile Laser Tag Rock Climbing Walls Billiards Bowling Bungee Trampolines NOTE: If you have any of these activities we may require additional information. Page 9 of 11

10 SIGNATURE PAGE Section 11: Cyber Liability 1. Do you process payment cards? 2. Estimated annual number of payment card transactions Section 12: WARRANTY (Applies to all parts of this application and attachments submitted) It is hereby understood and agreed that if insurance is issued by virtue of completing this application and any applicable supplemental applications, the Insurance is only issued on the reliance on the applicant s warranty of answers to the questions above and on any such supplemental applications. If, at the time a certificate/policy is issued and ANY OF ABOVE WARRANTIES IS IN ANY RESPECT INCORRECT, INCLUDING CLAIMS OR GROSS RECEIPTS, COVERAGE AFFORDED UNDER CERTIFICATE/POLICY shall, without notice to the applicant, immediately and automatically cease, & the certificate/policy shall BECOME NULL AND VOID. Warranties will survive a certificate/policy if issued. Section 13: SIGNATURE Print Name of Applicant Signature of Applicant (Mandatory) SUBMISSION CHECKLIST Title: Date: Please attach the following applicable documents along with your completed application: Waiver Facility diagram Emergency evacuation procedures Safety rules Business plan Resume (if less than 3 years in business) Lease agreement

11 FRAUD STATEMENTS FRAUD NOTICE GENERAL STATEMENT: Any person who knowingly and with intent to defraud any insurance company or another 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 the person to criminal and [NY: substantial] civil penalties. (t applicable in CO, DC, FL, HI, KS, MA, MN, NE, OH, OK, OR, VT or WA; in LA, ME, TN, and VA, insurance benefits may also be denied) APPLICABLE IN COLORADO: 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 policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement of award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. APPLICABLE IN DISTRICT OF COLUMBIA: 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. APPLICABLE IN FLORDIA: 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 degree. APPLICABLE IN HAWAII: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. APPLICABLE IN KANSAS: 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 statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial 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. APPLICABLE IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT: Any person who knowingly and with intent to defraud any insurance company or another 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, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties. APPLICABLE IN MINNESOTA: Any person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. APPLICABLE IN OHIO: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deception statement is guilty of insurance fraud. APPLICABLE IN OKLAHOMA: 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. APPLICABLE IN WASHINGTON: 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. I understand that the insurance company, in determining in whether to provide insurance coverage, will rely on the information contained in this form and all other information submitted. I hereby warrant, represent and confirm that, to the best of my knowledge, all information provided is complete, true and correct. Insured Signature: Date: