Canoe & Tube Rental Insurance Questionnaire

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

	Enter Number Below
Ranges
Ovens
Deep Fryers
Grills
Broilers
Griddles

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

3. Do you need Equipment Coverage?

YesNo

3a. If yes, total value to insure for?

Replacement CostActual CostTotal Value ($)

3b. If yes, please complete equipment schedule below or provide a separate equipment schedule with the following information:

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

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.)

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

2b. If yes, limits desired:

	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? ($)

WORKERS' COMPENSATION INSURANCE

1. 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/