Family Entertainment Center Insurance Questionnaire

Family Entertainment Center Insurance Questionnaire
Applicant's Name:*
Address:*
Mailing Address
Address (cont):*
Mailing Address - continued
Contact:*
Email*
Telephone:*
Website
Fax:
Applicant is:

IndividualPartnershipCorporationOther (specify)Other
Current Carrier:
Expiration Date:
Limits: ($)
Premium: ($)
Deductible: ($)
GENERAL INFORMATION - Please complete all questions in this section.
1. Describe your operations including a complete list of activities. Please attach a flier if available.
2. What are total receipts?
3. Are you open:

Year roundSeasonally
4. Hours of Operation
5. Number of years in business under present management:
6. Does applicant own or lease premises?

OwnLeaseOther Occupancies (Describe below)
6a. Please describe other occupancies
7. What is your annual payroll (excluding owners, officers, and support staff)?
7a. Number of owners/officers
7b. Please indicate the number of employees: (“Employees” include: Sole proprietors, Partners, Executive Officers, Seasonal employees, Part-time employees, Full-time employees.)

Rows Full-Time Part-Time

How many employees?
7c. What pre-employment screening is used? Please explain:
8. Do you host any special events?

YesNo
8a. If yes, please explain:
9. Additional Locations: (if different from mailing address above)
10. Do you require participants to sign a waiver of liability? (If yes, please attach a copy.)

YesNo
11. What is the minimum age allowed?
11a. If under 18 years old, do parents or guardians have to sign the waiver also?

YesNo
12. Do you ever hire sub-contractors/independent contractors that carry their own insurance?

YesNo
12a. If yes, please describe:
12b. If yes, are certificates of insurance provided?

YesNo
12c. Do subcontractors name you as additional insured on their policy?

YesNo
12d. Total Cost ($)

Rows	Full-Time	Part-Time
How many employees?

ADDITIONAL INFORMATION
1. Parking facilities provided:

YesNo
1a. If yes, are they lighted?

YesNo
2. Describe security (armed/unarmed):
3. Is security present during open hours?

YesNo
3a. Closed hours?

YesNo
4. Do you have a formal operations/training guide?

YesNo
5. Describe first aid facilities:
6. Number of employees certified in CPR:
6a. Minimum # of CPR trained employees on duty at any time:
7. Distance to ambulance/response time:
8. Emergency lighting?

YesNo
8a. Surveillance cameras?

YesNo
8b. Fire Alarm?

YesNo
9. Is Assumption of Risk signage placed throughout facility?

YesNo
10. Is there an emergency evacuation plan, medical emergency plan, disaster/crisis plan?

YesNo
11. Are special parties offered after normal business hours?

YesNo
11a. If yes, is the general public allowed on premises during this time?

YesNo
12. Are all exits from the building clearly marked?

YesNo
ATTRACTION INFORMATION
Arcades/Amusements
1. Do you offer arcades or similar amusement devices?

YesNo

1a. If yes, complete table below:

Rows	Enter number below
Arcade Receipts ($)
Number of Units
Number of Attendants

2. Does the insured own or lease the games?

OwnLease
3. Who provides service/maintenance on machines?
4. Do you have non-slip, non-conductive floor covering?

YesNo
5. Are all machines properly grounded?

YesNo
6. Are there any coin-operated rides?

YesNo
7. Any interactive games or ride simulators?

YesNo
7a. If yes, please describe:
Batting Cages - If yes, please attach waiver/release form.
1. Do you offer batting cages?

YesNo

1a. If yes, complete table below:

Rows	Enter number below
Batting Cage Receipts ($)
Number of Units
Number of Attendants

2. Minimum Age:
3. Are participants allowed to swing bats outside of batting cages?

YesNo
4. Is there a light or other indicator to show when the final ball is pitched?

YesNo
5. Are Reduced Injury Factor (RIF) baseballs used?

YesNo
6. One person in the batting cage at a time (i.e. Batter only)

YesNo
7. Helmets must be worn

YesNo
8. Batting cage must be self-contained and fully enclosed on all sides and on top

YesNo
9. Rules of the cage must be posted (Please provide picture of sign.)

YesNo
10. Maximum speed of machine: 80 mph

YesNo

Billiards
1. Do you offer billiards?

YesNo
2. Receipts:

3. Indicate the number of tables:

Rows	Number
Bar size Table
4’ x 8’ Table
4.5’ x 9’ Table
Snooker
Billiard

Bowling - If yes, please attach waiver/release form.
1. Do you offer bowling?

YesNo

1a. If yes, complete table below:

Rows	Enter number below
Bowling Receipts ($)
Number of Lanes
Number of Attendants

2. Total cost per lane: (Cost includes individual lanes, ball returns, pin-setting equipment, score projectors, score tables, scoring devices, player seating, spectator benches, etc.)
3. Does your bowling center have automatic scoring equipment?

YesNo
4. Do employees repair and/or maintain the automatic bowling equipment?

YesNo
4a. If no, who services?
5. Are food and drinks restricted from bowling area?

YesNo
6. Lane construction:

WoodSynthetic
6a. Lane Finish:

OilWater Base
7. Do you or an outside company refinish the lanes?

YouOutside Company
7a. Do you require a Certificate of Insurance from refinisher?

YesNo
7b. Is refinishing material used flammable?

YesNo
7c. Are flammables stored in U.L. approved containers?

YesNo
8. Is there child care for league bowlers?

YesNo
9. Pro Shop Receipts

Your operationLessor’s risk (rental income if leased out)Receipts/Rent ($)
Climbing Walls - If yes, please attach waiver/release form.
1. Do you offer climbing walls?

YesNo

1a. If yes, complete table below:

Rows	Enter number below
Climbing Wall Receipts ($)
Number of Attendants
Number of Climbers

2. How many walls are being used?
2a. Height/Width of wall(s):
3. If portable...
3a. How are walls transported?
3b. Does operator stay with walls?

YesNo
4. If stationary...
4a. Are walls part of another operation?

YesNo
4b. If yes, what type?
5. Do all climbers sign waivers?

YesNo
5a. Minimum age allowed:
6. Do you allow climbers to use personal equipment?

YesNo
6a. If yes, describe your policy with respect to screening of personal equipment used by others:
7. Are all belayers certified/trained?

YesNo
8. What type of belay device is used?
8a. If an auto belay device, how old is the device, date of last inspection, and who is the manufacturer?
9. Is there a minimum of 6-12 inches of fall protection beneath climbing wall, out to distance of 6 to 8 feet?

YesNo
10. What type of material is used in the landing area?
11. Is a daily inspection of the wall performed and results documented?

YesNo
12. Is wall maintenance conducted by an independent contractor who provides a certificate of insurance?

YesNo
13. Is all climbing safety equipment inspected, with inspection results documented?

YesNo
14. Are safety rules posted?

YesNo

Concessions (Food & Beverages)
1. Do you offer food and beverage concessions?

YesNo

1a. If yes, complete table below:

Rows	Enter number below
Concession Receipts ($)
Number of Stands
Square Footage

2. What is restaurant exposure?

Full-ServeSnack BarLessor's Risk
3. Is fast food delivery service available?

YesNo
4. Are food operations handled by?

InsuredSubcontractor
4a. If subcontracted, is certificate collected?

YesNo
5. Is there cooking on premises?

YesNo

5a. If yes, indicate which of the following apply and the number of each:

Rows	Enter Number Below
Ranges
Ovens
Deep Fryers
Grills
Broilers
Griddles

6. Is there a 40 BC fire extinguisher in the kitchen?

YesNo
6a. If yes, last date serviced:
7. Is there an automatic ansul system protecting cooking/frying surfaces?

YesNo
8. Hoods/ducts cleaned by contractor?

YesNo
8a. How often?

MonthlyQuarterlySemi-AnnuallyAnnually
9. Do you serve alcohol at your operation?

YesNo
9a. If yes, what is annual gross sales of beer, wine and liquor?
9b. If yes: Who is providing the liquor liability coverage?
9c. If yes: Who is providing the security in the area where the liquor is being served?
9d. Will you allow others to serve alcohol at this event? (If yes, Certificates of Insurance are required.)

YesNo
Note: If Liquor Liability coverage is desired, please contact Kevin Morency for a quote. (Liquor Liability will only be available if we provide the General Liability for your family entertainment center operation.)
Golf Driving Range
1. Do you offer a golf driving range?

YesNo

1a. If yes, complete table below:

Rows	Enter number below
Driving Range Receipts ($)
Number of Stalls/Tee Boxes

2. Are there partitions between stalls/tee boxes?

YesNo
2a. Describe partitions between tee boxes.
3. Maximum one (1) person allowed per tee box?

YesNo
4. Are other attractions exposed to the range?

YesNo
4a. Explain:
4b. Do all ranges face away from the public access areas?

YesNo
5. Is the range fenced in?

YesNo
6. Is there a safety zone of at least 30 feet between the range, parking lots, roads, etc.?

YesNo
Miniature Golf
1. Do you offer miniature golf?

YesNo

1a. If yes, complete table below:

Rows	Enter number below
Mini-Golf Receipts ($)
Number of Attendants
Total Number of Holes
Number of Courses

2. Do fountains and waterfalls have ground fault interrupters in place?

YesNo
3. Is appropriate safety warning and rule/regulation signs posted at club rental counter and/or hole #1?

YesNo

Escape Room - If yes, please attach waiver/release form.
1. Do you offer escape room(s)?

YesNo
2. What are total annual receipts?
3. Price of admission
4. Average number of visitors annually?
5. Maximum number of players?
6. Do you require participants to sign a waiver of liability? (If yes, please attach a copy.)

YesNo
7. What is the minimum age allowed?
8. Is escape room(s) locked?

YesNo
8a. If yes, how do customers get out in an emergency:
9. Number of Rooms
10. Room Dimensions:
11. Length of Game:

45 Minutes60 Minutes
12. Are live actors in the room?

YesNo
13. Do you use live animals in your escape room(s)?

YesNo
13a. If yes, please describe:
14. Do you have special effects or devices?

YesNo
14a. If yes, please describe:
15. Please describe theme of each room:
16. Do you use music in your rooms?

YesNo
16a. If yes, please describe:
17. Are fire extinguishers on site? (Valid inspection tag required)

YesNo
18. Are there smoke detectors?

YesNo
19. Is there a sprinkler system?

YesNo
20. Did the fire department conduct an inspection?

YesNo
21. Do you have a certificate of occupancy?

YesNo

Haunted House - If yes, please attach waiver/release form.
1. Do you offer a haunted house? (If Yes, please answer the following questions.)

YesNo
1a. If yes, total number of attendees
2. The haunted house is:

InsideOutside

Please answer the following questions:

Rows	Yes	No
3. If outdoors, is the area fenced?
4. Are any candles used?
5. Is there any human contact?
6. Is there any use of live animals?
7. Are there any moving floors, walls or steps?
8. Are there any slides?
9. Are bleachers or platforms used?
10. Are smoke effects used?
11. Are extension cords used?
12. Is the haunted house inspected by the fire department prior to use?
13. Are there age restrictions/limits?
14. Is first aid available?

15. If yes to any of above questions, please explain:

Please complete table:

Rows	Enter info below
16. Maximum number of individuals in house at one time:
17. Number of days open:
18. Hours of operations:
19. Anticipated number of people to go through the haunted house:
20. Estimated gross receipts:
21. Price of admission:

22. Any special handling of young children?

YesNo
23. Do you use lead or follow-up guides?

YesNo
24. Door monitors?

YesNo
25. Are exit signs clearly marked and illuminated?

YesNo
26. Describe any other events going on during the operation of the haunted house (DJ, bands, hay rides, etc.):
27. If transportation is used to move attendees to the house, please explain the type of transportation, the distance they will travel, and how it is powered:
28. Type of building:
29. Usual use:
30. Number of stories:
31. Age of building:
32. Square footage of building open to the public:
33. What type of divisions/walls?
34. Describe lighting on stairs:
35. If private security is used, how many guards?

N/AHow many guards?

Inflatables - If yes, please attach waiver/release form.
1. Do you offer inflatables? (If Yes, please answer the following questions.)

YesNo

1a. Please complete table:

Rows	Amount
Inflatable Receipts ($)
Number of Units
Number of Attendants

2. Describe any losses or incidents in past three years:
3. Are all inflatables properly anchored/secured/tied down?

YesNo
4. Type of flooring in inflatables area:
5. Do inflatables have signs clearly indicating age, height, size, capacity requirements?

YesNo
6. Are your inflatables inspected by the state and/or your employees?

YesNo
7. Are all inflatables manned by an operator/attendant?

YesNo

8. Equipment Inspection

Rows	Yes	No
8a. Is the equipment inspected daily or after each use?
8b. If yes, are inspection records maintained?
8c. If yes, are time period inspection records kept?

9. Renting Inflatables

Rows	Yes	No
Do you rent inflatables? (If yes, attach a copy of the rental agreement)
If yes, a) Are they rented with operators/attendants?
If yes, b) Do you deliver the inflatables?
If yes, c) Do you set up the inflatables?
If yes, d) Do you tear down inflatables?
If yes, e) Do you use the manufacturer’s checklist for the set up and use of the equipment?
If yes, f) When used outdoors, are there procedures to suspend use during inclement weather?
If yes, g) Does Rental Agreement have a Hold Harmless Clause?

10. Please complete chart below or provide a separate schedule with the following information:

Rows	Manufacturer	Type of Inflatable, Slide	Age/Height	Attraction Dimension	Capacity (Max)	Height of side
Item 1
Item 2
Item 3
Item 4

11. Other items rented (tents, chairs, snow cone machines, etc.) Include gross sales of each

Rows	Describe Item	Gross Sales
Item 1
Item 2
Item 3
Item 4
Item 5
Item 6
Item 7

11. Other operations: (concessions, games, etc.) Include gross sales of each

Rows	Describe Operation	Gross Sales
Operation 1
Operation 2
Operation 3
Operation 4
Operation 5

Soft Play/Ball Crawl
1. Do you offer soft play or ball crawl?

YesNo
2. Receipts ($)
3. Number of employees supervising play area:
4. Describe:
5. Are there signs indicating age, height or size limitations?

YesNo
6. Is there playground equipment?

YesNo
7. What type of flooring under equipment?

Museums - If yes, please attach newsletter and any brochures.
1. Do you offer a children's museum or local history museum?

YesNo
2. Are you on the National Register of Historic places? If yes, you are not eligible for program.

YesNo
3. Please describe your museum facility (collections, activities, special events, snack bar, gift shop, etc.)
4. Do you own the facility?

YesNo
4a. If no, who is the owner?
4b. Is your location address listed above? If not, please list location(s).
4c. Do you have an emergency plan (tornado, fire, etc.)?

YesNo
5. What is the square footage of the museum?
6. Days and Hours of operation?
7. How many annual visitors?
8. Is your museum seasonal?

YesNo
8a. Do you have outdoor displays?

YesNo
8c. If yes, do you have a caretaker on premises year round?

YesNo
9. Do you have any high-value or sensitive displays?

YesNo
9a. Please describe display(s).
9b. Please describe how these displays are stored (protective glass, controlled temperatures, fire safety, etc.)
10. Do you repair, restore, retouch or conserve collections?

YesNo
10a. If yes, please describe.

11. Please enter amounts below

Rows	Owned Collections	Loan Collections
Limit of Insurance Desired
Deductible
Total Value
Average Value (Item)
Maximum Value (Item)
Percentage of current collection

12. Owned Collections

Rows	Yes	No
11a. Are permanent collections fully inventoried?
11b. Are all collections catalogued, photographed or videotaped?
11c. Are records stored electronically with an electronic copy stored off site?
11d. Do you have precious metals or gems part of the collection?
11e. Are items stored at least 12 inches off the ground?

12a. Date collection values were last updated.

13. Loaned Collections

Rows	Yes	No
13a. Are written loan agreements obtained for all collections loaned to you?
13b. Do agreements specify who is responsible for damage and insurance?
13c. Do you make a photographic record of objects in loaned collection?
13d. Is valuation agreed for total loss?
13e. Is valuation agreed for partial loss?

14. Please answer the following about collections:

Rows	On Loan From Others	Loaned To Others
14a. Who is responsible for insurance while property is in transit?
14b. Who is responsible for insurance at insured's premises?
14c. Who is responsible for insurance while at loaned premises?
14d. Are packers trained in proper packing methods for valuable items (Yes/No)

15. Please describe security at the museum (guards (armed/unarmed), security system components (fire, burglar, motion detection, glass breakage, door/window sensors, security cameras, etc.)
15a. If central station, name of monitoring company.
15b. If you have security cameras, how many hours do you save the camera recordings?
15c. Can security system operate during power failure?

YesNo
15d. Are high value displays individually alarmed?

YesNoOther

Paintball and Airsoft - If yes, please attach field safety rules and waiver/release form.
1. Do you offer paintball or airsoft?

YesNo
2. What are gross sales for:
2a. Field Play Activities (rentals, fills, paintballs sold, field fees)
2b. Pro Shop Receipts

Your operationLessor’s risk (rental income if leased out)Receipts/Rent ($)
2c. Customer equipment repair
2d. Other (Enter dollar amount below)
2e. Other - describe below
3. Maximum number of participants per game:
4. Minimum Age:

Please answer the following questions:

Rows	Yes	No
5. Are waivers signed by all participants (or by parents for minors)? (Please provide copy of waiver.)
6. Do staging areas have posted safety rules and procedures and are they supervised at all times?
7. Are written instructions and procedures provided to all participants?
8. Are safety briefings conducted for all players on game safety?
9. Are “Goggles On” signs posted at all entrances to play fields?
10. Are “Barrel Blocking Devices Required” signs posted at all exits from play fields?
11. Are participants who violate the safety rules ejected?
12. Are participants separated by level of experience?
13. Do you allow smoking or drinking before or during games?

14. Do you have or assign a referee to each game played?

YesNo
14a. If yes, what is ratio of players to referees?
14b. Please describe referees training procedures:
15. Are other services or activities provided on premise?

YesNo
15a. If yes, please descibe:
16. Are spectators properly protected from the paintball area?

YesNo
17. Outdoor (Please complete for outdoor fields and attach a copy of your rules)
17a. How many acres of land do you own or lease?
17b. How many fields do you have for play?
17c. Is property fenced and/or posted “No Trespassing”? (Please provide picture.)
17d. Are games played after dark? (If yes, provide a copy of night time rules of play.)

YesNo
17e. If yes, is adequate lighting provided?

YesNo
17f. Please describe natural and manmade hazards: (i.e. cliffs, ravines, water, gun pits, slides, etc.)
17g. Are players made aware of these hazards?

YesNo
17h. How often is your field inspected for hazards?
18. Indoor (Please complete for indoor fields and attach a copy of your rules)
18a. What is the square footage of the buildings?
18b. Number of stories?
18c. What type of floor covering do you have: (i.e. carpet, sawdust, sand, etc.)
18d. Is protective covering for walls and ceiling provided?

YesNo
18e. If yes, describe.
18f. Is emergency lighting provided?

YesNo
18g. Are exits marked?

YesNo
18h. If yes, describe.
19. Do you use inflatables as obstacles on the course?

YesNo
19a. If yes, how are they anchored?

Please answer the following questions

Rows	Yes	No
20. Are there any climbing structures 3 feet or higher used in the area of play? (Please attach photos.)
20a. Are steps or ramps or handrails used on all climbing structures?
20b. Are there grip tapes on the ramps and stairs?
21. Does all the equipment meet ASTM standards?
22. Do you examine and maintain the equipment you lend out daily?

23. What is the average age of rental equipment?

Please answer the following questions

Rows	Yes	No
24. Are facemasks or goggles required and is their usage enforced?
25. Do you have anti-fogging eye protection equipment?
26. Can players use fog-free equipment for an additional fee?
27. Do you allow players to bring their own equipment?
27a. If yes, do you verify that fps (feet per second) is less than 300?
27b. If yes, do you allow automatic or modified markers?
28. Do you inspect equipment brought onto premise and recalibrate markers if necessary?
29. Do you have a minimum of one working chronograph at all times?

30. What type of protective gear is supplied to participants?
31. What is the feet per second (fps) used at your facility?

Rows Indoor Outdoor

FPS
32. What type of air system is used?
33. Are all markers required to have barrel plugs and safety locks?

YesNo
34. Do you permit full automatic or burst/turbo shooting?

YesNo
35. Do you perform any repairs or modifications to customer’s markers?

YesNo
35a. If yes, please describe training required to service:
36. Do you sell US made products?

YesNo
37. Do you purchase products through a US wholesaler?

YesNo
38. Do manufacturers provide certificates of insurance naming you as additional insured?

YesNo
39. Do you have a formal maintenance plan?

YesNo
40. How often is equipment inspected?
41. Do you sponsor any OFF PREMISE events?

YesNo
41a. If yes, please describe:
42. Are you or your employees trained or certified to fill and refill CO2 cartridges?

YesNo
43. Do you allow players to fill their own tanks? (If yes, please explain procedure followed on a separate sheet.)

YesNo
44. Where are your CO2 tanks stored and how are they secured?

Rows	Indoor	Outdoor
FPS

Laser Tag - If yes, please attach waiver/release form.
1. Do you offer laser tag? (If Yes, please answer the following questions.)

YesNo

1a. Please complete table:

Rows	Amount
Lasert Tag Receipts ($)
Number of Attendants

2. Are adults and children allowed to participate in the playing zone at the same time?

YesNo
3. What is the maximum number of players allowed in the playing zone at one time?
4. Do you use Game Masters/Referees in the playing zone?

YesNo
4a. If yes, what is the ratio of players to game masters/referees?
4b. Please describe your procedure for training of the game masters:

Please answer the following questions:

Rows	Yes	No
5. Do staging areas have Safety Rules posted? (If yes, please provide picture.)
5a. If yes, do they include no running, climbing, crawling and physical contact warning signs?
6. Are safety briefings held prior to being allowed to play?
7. Do you examine and maintain your equipment and premises daily prior to use?
8. Are all exits from the playing zone to the main part of the building clearly marked?

9. What type of lighting exists in the playing zone?
9a. Is there an emergency lighting system?

YesNo
Skate Park - If yes, please attach waiver/release form.
1. Do you offer a skate park? (If Yes, please answer the following questions.)

YesNo

1a. Please complete table:

Rows	Amount
Skate Park Admissions ($)
Sales ($)
Rentals ($)

2. Location (if different from mailing address above)
3. Construction of facility (i.e. brick/frame, etc…outdoor/indoor)
4. What is the size of the park?
5. Number of Attendants

6. Average daily attendance:

Rows	Attendance Number
During the week
Weekends
Summer Days

7. What types of sports are allowed?

Rows	Yes	No
7a. In-line Skating?
7b. Hockey?
7c. BMX Cycling?
7d. Skateboarding?
7e. Other?

7f. If other, describe:

Skating Rinks - If yes, please attach waiver/release form.
1. Do offer skating activities (roller, in-line, ice)?

YesNo
1a. Is rink open year round?

YesNo
1b. If no, please list months in operation:
1c. What are your hours of operation:

2. During open skate – Minimum number of employees on duty:

Rows	On Rink	Off Rink
Minimum Number of Employees During Open Skate

3. Do you offer?

DancingSkating LessonsSkating CompetitionsOther - Describe

Please answer the following:

Rows	Yes	No
3a. Are instructors on premises during sessions?
3b. Are instructors on premises outside of sessions?
3c. Are instructors employees of the applicant?
3d. Do instructors obtain releases & waivers from students and/or parents? (Please provide a copy of agreement.)

5. Gross Annual Receipts

Rows	Ice Rink	In-Line Facility	Roller Rink
Gross Annual Receipts
Facility Rental - Association (clubs & events)
Facility Rental - High School & College
Facility Rental - US Figure Skating
Facility Rental - USA Hockey*
Facility Rental - Non-skating events
TOTAL
Other: (Describe below)

5a. Describe Other
5b. *List all USA Hockey Teams/Leagues that skate at your facility:
5c. Pro Shop Receipts

Your operationLessor’s risk (rental income if leased out)Receipts/Rent ($)
6. Is there a barrier that separates all skating areas from spectators and other activities?

YesNo
6a. If yes, what is barrier height:
7. Do you offer any “all night” or “midnight” skating?

YesNo
7a. If yes, what ages are allowed?
7b. What hours?
7c. What time is admission no longer permitted?
7d. What are drop-off and pick-up guidelines?
7e. What are the guidelines in place that outline who is allowed to leave the facility and at what time?
8. Do you conduct regular maintenance, inspection and replacement of rental skates?

YesNo
9. Do you keep a skate maintenance log?

YesNo
10. Do you number your skates?

YesNo
11. Do you have any sponsoring or sanctioning organizational affiliations or associations?

YesNo
11a. If yes, please check names:

USAC/RDUSA Roller HockeyISIAHIHAUSFSANRHARSARHIAOther
11b. List 11a"Others"
12. Roller Rink

YesNo
12a. Surface Composition:
12b. Overall condition of floor material:
12c. Age
12d. Is there regularly scheduled maintenance of the floor?

YesNo
12e. If yes, describe floor maintenance and who performs work:
12f. Number of Skating Surfaces:
12g. Maximum rink capacity at any one time:
12h. Number of rink guards
12i. Maximum number of skaters per floor per floor guard?
13. Ice Rink

YesNo

13a. Number and type of skating surfaces:

Rows	Ice	In-Line	Other
Indoor
Outdoor

13b. Maximum rink capacity at any one time:
13c. Number of rink guards
13d. Maximum number of skaters per floor per floor guard?
13e. Is there regular maintenance of ice surfacing equipment?

YesNo
13f. If yes, by whom:
13g. Experience:
13h. Fuel source of ice resurfacing equipment:

GasElectricPropane
13i. What is the construction of ice refrigeration equipment?

1” diameter steel piping with welded connections1/2'” diameter steel tubingPlastic mat piping
13j. Is there proper draining in ice resurfacing room?

YesNo
13k. Is the piping accessible by crawl space or lower level access?

YesNo
13l. If no, explain (buried in concrete, gravel, sand, etc.)
13m. Is the ice surface ever covered or removed for other activities?

YesNo
13n. If yes, do you require contract with hold harmless and collect additional insured certificate?

YesNo

14. Complete this section for any competitive sports, such as hockey, broomball, etc.

Rows	Yes	No
14a. Are barriers installed behind goals?
14b. Are barriers installed around perimeter and surface?
14c. Are barriers plexiglass?
14d. If yes, is plexiglass barrier strutted?
14e. If yes, is plexiglass barrier seamed?
14f. Wire Mesh or Chain Link?
14g. Do you have dasher boards?
14h. Do you have netting?
14i. Do you have hockey nets?
14j. If you have hockey nets, are they breakaway/rest on surface?
14k. If you have hockey nets, are they anchored/bolted to surface?

14l. What are the heights of the barriers behind the goals and sides?

Zip Lines - If yes, please attach waiver/release form.
1. Do you offer a zip line? (If Yes, please answer the following questions.)

YesNo
2. Annual gross revenue for zip line activities:
3. Total number of participants each year:
4. How long have you been operating zip lines at this business?
5. Are waivers signed by all participants (or by parents for minors)? (Please provide copy of waiver.)

YesNo
6. Are all participants required to wear a helmet?

YesNo

7. Please provide minimum and maximum participant height and age range:

Rows	Minimum	Maximum
Age
Weight

7a. Are these weight limits based on course builders/designers recommendations?

YesNo
8. What type of harnesses do you use?

Waist HarnessFull Body HarnessBoth
9. What experience requirement, training and certification do you require for zip line guides/operators?
10. What is the maximum height of the course?
11. How many zip lines does the tour consist of and what is the length of each?
12. How long does the ride last?
13. What is the max speed of the fastest zip line?
14. Do you own or lease the zip line?

OwnLease
14a. If lease, describe the arrangement:
15. Who originally built the course?
15a. What year was the course originally built?
15b. Were Certificates of Insurance obtained?

YesNo
16. Was the course built to ACCT or ANS/PRCA standards?

YesNo
16a. If neither, whose standards were followed?
17. Have you made any additions or alterations to the course since it was built?

YesNo
17a. If yes, list date added, type of alteration (or element added), and construction vendor name:
18. Date of last course inspection by professional firm (Month/Year/Name of Firm):
18a. Have you made recommended improvements to course since last inspection?

YesNoNot Applicable
19. How often is the course inspected?

MonthlyQuarterlySemi-AnnuallyAnnuallyOther
20. Describe the maintenance program for the zip lines and all safety equipment:
21. How many cycles per zip line before you retire and replace the line?
22. What type of braking system is used?

ActivePassive
23. Do you maintain a written log documenting inspections of lines and related equipment?

YesNo
24. Do you have padding on your platforms or trees/poles?

YesNo
25. Do you provide services after dark, including but not limited to, night zip lining and overnight camping?

YesNo
25a.If yes, please describe.
26. Is the entire course rented to outside groups or individuals? (If yes, please provide copy of rental contract.)

YesNo

Spectator Areas - If yes, please provide picture of spectator areas.
1. Do you have a spectator area?

YesNo
2. Type of seating:

Folding ChairsWooden BleachersAluminum, Metal or Steel Bleachers
3. If bleachers are used, is the style:

OpenClosed
3a. Are railings in place?

YesNo
4. How many spectators can the above seating accommodate, per manufacturer’s recommendations?
5. Is the maintenance conducted by?

Independent ContractorTrained Employee

Please answer the following questions:

Rows	Yes	No
6. Are inspections completed of spectator seating?
7. Is an inspection log maintained?
8. Is crowd control available for larger events, such as games?
9. Is there seating behind the goals?
9a. If yes, is there netting to the ceiling?

MISCELLANEOUS
1. Other activities: (check if applicable)

DJ/Live BandsEntertainmentHorseshoe PitsSlot/video poker machinesSoftball DiamondsVolleyball CourtsOther sports/athletic activities - describe belowOther patron participation events (i.e. sumo wrestling, bungee, etc.) - describe below
Other sports/athletic activities - Describe
Other patron participation events (i.e. sumo wrestling, bungee, etc.) If yes, please explain:
2. Is there a dance floor?

YesNo
3. Do you have live entertainment?

YesNo
3a. If yes, please describe:
4. Do you have tenants?

YesNo
4a. If yes, do you obtain a certificate of insurance with limits of $1,000,000?

YesNo
4b. Please list each tenant and operation/relationship

SEXUAL ABUSE - (If located in Illinois, this section MUST be completed. If located in other states, complete only if you desire coverage.)

1. Does the applicant perform a criminal background investigation, including sexual abuse or child abuse-related offenses:

Rows	Yes	No
1a. On prospective employees and volunteers?
1b. On existing employees and volunteers?

1c. How often?
2. Does the applicant verify employment/volunteer-related references?

YesNo
2a. If yes, how?
2b. If yes, how often?
3. Does the applicant conduct personal interviews?

YesNo

4. Does the applicant discuss the following items at staff orientation:

Rows	Yes	No
4a. Abuse and Molestation?
4b. How to recognize the signs of abuse?
4c. What to do if an individual reports someone molested him/her?

5. Does applicant have supervision plan to monitor staff in day-to-day relationships with clients/children?

YesNo
6. Does the applicant have knowledge of any incident which could give rise to, or result in, an allegation of sexual abuse?

YesNo
6a. If yes, please explain:
7. Has there ever been an allegation of sexual abuse made against the insured?

YesNo
7a. If yes, please explain:

PROPERTY INSURANCE
1. Do you need Building and/or Content Coverage?

YesNo

1a. If yes, please complete chart below or provide a separate property schedule with the following information:

Rows	Building Age	Building Construction	Building Limit ($)	Content Limit ($)
Building 1
Building 2

2. Do you need Equipment Coverage?

YesNo
2a. If yes, total value to insure for?

Replacement CostActual CostTotal Value ($)

2b. If yes, please complete equipment schedule below or provide a separate equipment schedule with the following information:

Rows	Year	Make	Model	Value to Insure For ($)
Item 1
Item 2
Item 3

COMMERCIAL CRIME
1. Do you desire coverage for Crime (Employee Dishonesty, Money, Forgery)?

YesNo
1a. If yes, requested amount?
OPTIONAL PROPERTY COVERAGES
1. Do you need Computer Coverage?

YesNo
1a. If yes, amount needed?
2. Do you need Outdoor Sign Coverage?

YesNo
COMMERCIAL AUTOMOBILE INSURANCE
1. Does the business title any automobiles or other operating vehicles in the business name?

YesNo
2. Is insurance coverage needed for owned automobiles?

YesNo

2a. (If yes, complete chart below or provide a separate vehicle/fleet schedule with following info.)

Rows	Vehicle Make	Vehicle Model	Cost New ($)	Year
Vehicle 1
Vehicle 2
Vehicle 3

2b. If yes, limits desired:

Rows	Amount ($)
Limit of Liability
Comprehensive Deductible
Collision Deductible

3. Do any of the employees, owners or officers drive personally owned automobiles/other vehicles in the course of their work?

YesNo
3a. If yes, how many?
3b. Do you verify they have liability coverage?

YesNo
3c. Limits? ($)
COMMERCIAL UMBRELLA
1. Do you need a Commercial Umbrella?

YesNo
1a. If yes, limit of liability needed? ($)
DIRECTORS & OFFICERS LIABILITY AND WORKERS' COMPENSATION INSURANCE
1. Do you need Directors and Officers Liability Coverage? (If yes, please contact Kevin Morency.)

YesNo
2. Do you need Workers Compensation? (If yes, please contact Kevin Morency.)

YesNo
SIGNATURE
The information I have provided is true and accurate to the best of my knowledge. I have not willfully concealed or misrepresented any material fact(s) or information. I understand completion of this questionnaire does not compel the company to provide coverage.
Signature
Or Enter Your Full Name as Signature:
Date:
Questions? 877-244-9090
Kevin Morency | kmorency@morencyinsurance.com

Morency & Associates Inc.
141 New Shackle Island Rd, Hendersonville, TN 37075
Fax: 615-452-6580

https://familyfuninsurance.com/
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