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ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER 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 MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER 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 SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME.
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 DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.
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.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER 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 SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.
ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON A N APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
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
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD OR SOLICIT ANOTHER TO DEFRAUD AN INSURER: (1) BY SUBMITTING AN APPLICATION, OR (2) BY FILING A CLAIM CONTAINING A FALSE STATEMENT AS TO ANY MATERIAL FACT, MAY BE VIOLATING STATE LAW
“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.”
“ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.”
“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.”
Insured’s Legal Name:
Entity Type: Sole Proprietor Partnership Corporation Other
Location Address:
City:
County:
State: AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip:
Mailing Address (If different):
Email:
Phone:
Fax:
Tax ID Number:
Website / Facebook:
**NEXT 12 MONTHS
Bowling (including Shoe Rental) $
Restaurant/Snack Bar $
Pro Shop $
Arcade $
Liquor $
Vending $
Laser Tag $
Mini Golf $
Bumper Cars $
Batting Cages $
Go Carts, Skating Rink, Billiards $
Inflatables $
Other $ $ $
** This information is not required, however, this information will help us to better analyze your account needs and will also help us to obtain the most competitive quote!
Current Property Carrier:
Annual Premium $
Current Building Coverage: $
Current Contents Coverage: $
Do you have coverage for
Equipment Breakdown: $
Signs: $
Wind & Hail Deductible: $ or %
100% value of bowling lanes and bowling equiptment: $
Business income limit: $
Bowling lane equipment to be covered: Replacement cost ACT
Bowling lane equipment values are covered in: Building value Contents value
Current General Liability Carrier:
Annual Premium: $
Current Limits of Liability: $
Current Liquor Carrier:
Limits of Liquor Liability: $
Current Workers Compensation Carrier:
States Covered:
Current Employers Liability Limits
Bodily Injury by Accident/ Each Accident: $500,000 / $500,000 $1,000,000 / $1,000,000
Current Liquor Carrier: $500,000 / $500,000 $1,000,000 / $1,000,000
Workers Compensation Experience Modifier (if known):
Hours of Operation: Sun: Mon-Thur: Fri-Sat:
Total Years in Business:
At This Location:
Number of Lanes:
Do you contract lane refinishing: Yes No
Lane Construction: Wood Synthetic
Are ball racks secured/anchored to the floor? Yes No
Does your bowling center have automatic Scoring equipment? Yes No
Are any flammable liquids stored on premises? Yes No
If Yes, list products & quantities:
Are all flammable liquids stored in UL approved containers? Yes No
Percentage of business from:
League activity: %
Open Play: %
Do you sponsor any professional tournaments? Yes No
If Yes, list events and sponsoring organization:
If Yes, are certificates of insurance obtained from sponsoring organization? Yes No
Do you have a pro shop on premises? Yes No
Is your pro shop: Employee Independent Contractor
If an Independent Contractor, is insurance placed elsewhere? Yes No
If leased to a third party, please provide the square footage:
Does your bowling center have amusement devices or arcade? Yes No
If Yes, indicate number of each:
Electronic Games:
Pool Tables:
Pinball Machines:
Mechanical Bulls:
Dart Machines:
Gaming Machines:
Other (Describe):
Leased or Owned:
Do you lease your facility for birthday parties or banquets? Yes No
Please describe the type of Banquets?
Do you provide child care services? Yes No
Do you perform background checks on your adult staff, whether volunteers or paid employees? Yes No
Any other activities or business operations? Yes No
Please Describe:
Please check all that apply: Snack Bar Restaurant Bar Banquet Hall
Is the restaurant leased to a third party? Yes No
Are all cooking surfaces protected by a hood and duct system? Yes No
Do you have a service contract with a contractor to clean the hood and duct system? Yes No
Is there an automatic extinguishing system? Yes No
What type of automatic extinguishing system is in place?
UL300: Wet Dry
How often is the system serviced and maintained? Monthly Quarterly Semi-Annual Annual
When was the system last inspected and serviced?
Do you have a deep fat fryer on premises? Yes No
Are portable fire extinguishers provided in the kitchen? Yes No
Last Service Date:
Are food and beverages permitted in the bowling area? Yes No
Year Constructed
If over 20 years old, please provide date and description of last update to
Electric:
Heating:
Plumbing:
Roof:
Roof type: Flat Bowstring truss Etc
If bowstring truss, date of last inspection:
Building Construction: Block Metal Frame Other
Building Area in Square Feet:
100% Value of Bowling Lanes and Bowling Equipment: $
Bowling Lanes and Equipment to be covered Replacement Cost ACV:
Bowling Lanes and Equipment Values are included in: Building Value Contents Value
What is the age of the roof cover?
Roof materials are: Asphalt Shingles Built-up Roof Metal Modified Bitumen Slate EPDM (Rubber Membrane) Concrete Tile Sprayed Polyurethane Foam Clay Tile Roll Roofing Wood Shake PVC Membrane Other
What is the roof support made of? Bowstring truss Steel I-Beam Steel Truss Glue Lam Beam
What is the roof covering made of? Membrane Asphalt Shingle Metal Hot-Mop or Torch Down
Slope of the roof is considered?See definitions Conventional slope Flat slope Low slope
Has the building been exposed to a hail storm in the past 12 months? Yes- no damage Yes- with damage No
If yes with damage, has roof damage been repaired Yes No
Has the roof been replaced? Yes No
Do you have roof mounted equipment (HVAC, solar panels, process equipment,etc)? Yes No
Do you have skylights? Yes No
Do you have the roof inspected at least annually by a qualified person? Yes No
Have you experienced roof leaks in the past 12 months? Yes No
Is building protected by a sprinkler system? Yes No
Does the bowling center have any alarm systems? Yes No
Where do cameras provide coverage? inside outside parking lot
How long does the DVR keep footage?
Are burglar/fire alarms centrally monitored? Yes No No Idea
If yes, what type? Smoke/Heat Burglary Fire
Name of alarm monitoring service:
Security Cameras? Yes No
Who is your responding Fire Department?
Miles to Station:
Number of feet from Hydrant:
Which of the following does the Center use to minimize damage from lightning: Overload Circuit Breakers In-Line Lightning Resistors Surge Protectors Ground Fault Circuit Interrupters Other
Do you have a business auto policy for owned autos? Yes No
If you have more than one operation at the same location, provide breakdown of receipts by operation:
Bar/ Lounge
$
Restaurant
Banquet Hall
Retail Sales
Other
Liquor License name:
Liquor License Number:
Class of License:
Has your alcoholic beverage license ever been revoked or suspended? Yes No
If Yes, explain:
Have you had any occurrences that have arisen out of the sale of any alcoholic beverage? Yes No
Has your liquor liability insurance been canceled or non-renewed in the last 3 years? Yes No
Have you ever been fined by alcoholic beverage control or other governmental regulator? Yes No
Have you ever filed for Bankruptcy? Yes No
Type of alcoholic beverages sold:
What proof?
Are patrons allowed to carry alcoholic beverages onto the premises? Yes No
If Yes, what type?
Number of servers used:
Professional? (2 years bartender experience or more?) Yes No
Non-Professional (no bartender experience) Yes No
Explain:
Are all alcohol-serving employees certified in a formal alcohol training course? Yes No
TIPS TAM RAMP BEST OTHER
At what location are IDs checked and how often?
In what size container are alcoholic beverages served? Glass/Cup oz Pitcher oz Other oz
Is there a limit placed on the quantity of alcoholic beverages purchased at one time? Yes No
Do you serve beer or alcohol from “bar carts”? Yes No
Hours of operation for the bar / lounge: Monday through Thursday Friday Saturday Sunday
Is there a separate outside entrance to the bar or Lounge Area? Yes No
Does bowling center feature any entertainment? Yes No
How often?
Type of entertainment featured: DJ Jukebox Karaoke Solo Vocalist Band (1-3 members) Band (4+ members) Other
If musical entertainment, what type? Top 40’s Pop Classic Rock Soft Rock Alternative Country Jazz R&B Rap Other
Is dancing permitted? Yes No
Is there a dance floor? Yes No
If Yes, size of dance floor: Sq.Ft. Bar/Restaurant Sq.Ft. = %
Is there a minimum or cover charge? Yes No
Is the parking area patrolled to prevent intoxicated drivers from leaving the premises? Yes No
Is there any type of designated driver program in effect? Yes No
Describe security measures in place.
Number of uniformed police officers present at the site of alcohol sales:
Number of undercover police officers present:
Number of private security present:
Other:
Are rules and regulations clearly displayed for patrons’ viewing? Yes No
Other promotional activities or events?
Type of clientele: Area Residents Area Workers Tourists College Other
Average age of patrons:
Percentage of clientele: Under 25 25-30 Over 30
Current Liquor Limits: $
Current Liquor Premium: $
Each Common Cause: $500,000/$500,000 $1,000,000/$1,000,000
Aggregate: $500,000/$500,000 $1,000,000/$1,000,000
Is an Additional Insured needed?
Name:
Address:
Describe Interest: