Miniature Golf Insurance Questionnaire

Mini-Golf 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
1. Liability Coverage (check coverage desired):

General Liability – including injuries to participants
GL Occurrence Limits desired:
GL Aggregate Limits desired:
2. Please list locations and buildings at each location (List additional locations on separate page)
Location 1: Address and number of buildings
Location 2: Address and number of buildings

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

	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?

Mini-Golf Insurance Questionnaire