Gun/Archery Range Insurance Questionnaire

Gun/Archery Range Insurance Questionnaire
Applicant's Name:*
Address:*
Mailing Address
Address (cont):*
Mailing Address - continued
Contact:*
Email*
Telephone:*
Website
Fax:
Applicant is:

IndividualPartnershipCorporationOther (specify)
Current Carrier:
Expiration Date:
Limits: ($)
Premium: ($)
Deductible: ($)
Premises Information (Gun Range - Indoor, Outdoor, Pistol, Rifle, Shotgun; Archery Range; Archery Shop) - Gun Sales Ineligible

1. Please indicate the number of each type of range and the number of lanes per range.

2. What is the maximum distance of ranges?
3. What is the minimum age of an unsupervised shooter?
4. Are the ranges approved by the NRA or the state department of natural resources?

YesNo
4a. If no, what type and kind of backstop or berm is used?
5. Are all range controllers certified?

YesNo
6. Is a range master/supervisor on premise during shooting hours?

YesNo
7. Are range rules and safety guidelines posted in a conspicuous manner? (If yes, provide copy.)

YesNo
8. Are range users required to sign a liability waiver? (If yes, please provide copy of a waiver.)

YesNo
9. Is the range open to the public?

YesNo
10. Is the premise secured and locked when not operating?

YesNo
11. Do you sell any guns?

YesNo

12. Gross receipts from: (Please indicate “N/A” if the following doesn’t apply to applicant)

	Gross Receipts ($)
Archery equipment
Consignment sales
Factory ammo
Reloaded ammo
Bowsmithing
Range
Rental Equipment (Provide details below)
Other Sporting Goods (Provide details below)