Fillable FIREARMS TRAINING SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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FIREARMS TRAINING SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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The FIREARMS TRAINING SUPPLEMENTAL APPLICATION (Kinsale Insurance) form is 6 pages long and contains:

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  • 18 check-boxes
  • 162 other fields

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Page 1 of 6
FIREARMS TRAINING SUPPLEMENTAL APPLICATION
COMPLETE IN ADDITION TO ACORD APPLICATIONS.
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
1)
Named Insured:
Brokerage/Broker:
Agency/Agent:
Renewal? Yes No
Policy Number:
Effective Date:
Website:
2) Current Carrier Information:
Carrier:
Limit of Insurance:
Deductible:
Premium:
Offering renewal? Yes No
Claims made? Yes No Retroactive date:
Please attach copies of the following:
a) Currently valued five year loss runs, including claim detail for all losses open or exceeding $15,000
b) Applicant’s product brochure, catalog, or marketing materials if a website is not available
c) Copies of all course materials, guides, and maps as applicable
3) What are your operations? Check all that apply:
Firearms Training – Basic Safety and Use
Firearms Training – Self-Defense – No Contact
Firearms Training – Self-Defense – Including Disarm/Martial Arts Training
Firearms Training – Armory/Gunsmithing and Ammunition Reloading
Firearms Training – Advanced Tactical – Civilian
Firearms Training – Advanced Tactical – Law Enforcement, Military, or Licensed Security
Firearms Training – With Tactical Driving
Firearms Training – Trick Shooting or Film/Television Instruction
Firearms Training – Marksmanship/Professional Target Shooting
Bladed Weapon Training
Guided Hunt – On Foot/Trail
Guided Hunt – Utilizing Land or Marine Vehicles
Guided Hunt – Utilizing Aircraft or Rotorcraft
4) What are your projected receipts for the coming year? $
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 6
5) Do you operate seasonally only? Yes No
a. If yes, what is your operating season?
6) Are you subject to any state or local licensing or regulation? Yes No
a. If yes, list regulations/licenses:
7) How many years have you been in operation?
8) Do you run criminal background checks on all employees? Yes No
a. Are past convictions for violent crimes or organized crime, or “no fly list” restrictions Yes No
exclusionary criteria for hiring?
b. What is the minimum age for employment?
9) Does your operation have any age restrictions for participants? Yes No
a. If yes, what age? _
10) Do you strictly prohibit the use of firearms by any participants under the influence of drugs Yes No
or alcohol?
11) Are all participants required to sign a waiver absolving you of all liability for bodily injury Yes No
and property damage, including any damage to their firearms?
12) Please indicate the personal protective equipment required when firearms are being discharged:
a. Ear Protection? Yes No
b. Eye Protection? Yes No
d. Other : Yes No
13) Do you have the following first aid measures readily accessible in all areas where firearms are discharged:
a. Basic first aid kit? Yes No
b. First aid trained staff? Yes No
c. Advanced aid kits (such as gunshot, hemorrhage, tourniquet)? Yes No
d. Emergency alert button/911 call button? Yes No
14) How many students maximum will you train at one time?
a. Do you allow students to bring their own firearms?
b. Is classroom instruction completed and students assessed prior to any range instruction? Yes No
15) Do you instruct classes for students to satisfy a state or local requirement to obtain firearm Yes No
permitting such as a concealed carry license?
a. If yes, do state or local requirements mandate that you conduct any kind of student Yes No
screening?
b. If yes, please describe:
c. Does passing the course require a mandatory minimum proficiency? Yes No
d. What is the minimum accuracy threshold? %
16) Do any courses you offer involve live fire training/practice? Yes No
a. If yes, is this at a range you own, operate, or are an employee? If yes, please complete Yes No
Kinsale Shooting Range Supplemental Application and provide detailed diagrams of range(s).
Page 3 of 6
17) Do any courses offered require any special state or federal reporting? Yes No
a. If yes, please describe:
b. Are students aware of this reporting requirement? Yes No
18) Do you have any restrictions on course participation based on violent crimes, active Yes No
restraining orders, involuntary psychiatric holds, or “no fly” listings?
19) If you conduct any self-defense training or bladed weapons training, please complete the following:
a. Are all hand-to-hand training modules conducted with dummy weapons incapable Yes No
of firing a projectile?
b. If no, are modules conducted with nonlethal weapons only (paint projectiles, Taser, etc.)? Yes No
c. Describe the safety equipment utilized during hand-to-hand training modules (mats, headgear, etc.):
d. Are students instructed to or permitted to spar with one another? Yes No
20) If your conduct any advanced tactical courses, please complete the following:
a. Does any course work involve climbing or rappelling? Yes No
b. Do any course modules involve exposure to extreme elements or pain, including severe Yes No
temperatures, loud noises, strobing lights, obfuscated vision, low lighting, electroshock
devices, chemical irritants, visually disturbing imagery or scenery, harassment or
humiliation, explosions, fire, sleep deprivation or other severe high stress conditions?
c. If yes to b., are these modules conducted with live firearm/lethal projectiles present? Yes No
21) If you are conducting tactical driving courses, do students complete driving modules in Yes No
their own vehicles?
a. Are students permitted to fire weapons from the driver’s seat? Yes No
b. If yes to a., are students required to stop the vehicle before discharging? Yes No
22) Are any courses conducted over multiple days? Yes No
a. If yes, do you provide overnight accommodations? Yes No
b. If yes to a., are accommodations considered to be backwoods or primitive camping Yes No
in nature (no access to running water, conventional plumbing, or electricity)?
c. Do you provide meals? Yes No
d. Do you serve or permit BYOB alcohol consumption? Yes No
e. If yes to d., do you require all firearms to be unloaded and locked before alcohol may Yes No
be consumed?
23) Who maintains the trails/areas where hunts occur?
24) Do you confirm the validity of all participant hunting licenses before the hunt commences? Yes No
25) Do you conduct a safety presentation before the hunt commences? Yes No
a. Are participants required to wear high visibility vests or clothing? Yes No
b. Does your presentation include an overview of local, state, and federal limitations on Yes No
hunting (size limitations, protected species, scope of license/season, etc.)?
26) Do you conduct hunts of any apex predator/high predator game such as bears, alligators, or Yes No
Page 4 of 6
wild boar?
a. Do you conduct hunts in areas where apex predators are known to have habitats? Yes No
27) Do you conduct hunts using weapons other than firearms (bows, trapping)? Yes No
28) If you are utilizing non-aircraft vehicles, please complete the following:
a. Are participants permitted to drive? Yes No
b. If yes to a., are participants required to place the vehicle in park before shooting? Yes No
c. Are you utilizing any watercraft? Yes No
d. If yes to c., are participants required to wear a US Coast Guard approved life vest? Yes No
29) If you are utilizing aircraft or rotorcraft, please complete the following:
a. Are flights conducted open door? Yes No
b. If yes to a., how are participants secured in the aircraft?
c. Does any portion of the flight path go over water? Yes No
d. If yes to c., are all passenger restraints designed to allow for rapid egress? Yes No
e. How many pilots do you employ or contract?
f. How many flight hours does each pilot have in the type of craft you are operating?
g. Do you own the craft you use? Yes No
h. If no to g., are you responsible for regular maintenance of the craft? Yes No
i. Do you carry aircraft liability insurance including passenger and public liability? Yes No
30) Are any hunts conducted over multiple days? Yes No
a. If yes, do you provide overnight accommodations? Yes No
b. If yes to a., are accommodations considered to be backwoods or primitive camping Yes No
in nature (no access to running water, conventional plumbing, or electricity)?
c. Do you provide meals? Yes No
d. Do you serve or permit BYOB alcohol consumption? Yes No
e. If yes to d., do you require all firearms to be unloaded and locked before alcohol may Yes No
be consumed?
31) During the past five years, has any insurer ever canceled or non-renewed similar Yes No
insurance to any applicant or has your insurance been canceled for nonpayment of
premium by any insurance or finance company. If Yes, please attach and explanation.
32) Is your company aware of any occurrences, facts, circumstances, incidents, situations, Yes No
damages or accidents arising out of or related to your operations that a reasonably
prudent person might expect to give rise to a claim or lawsuit whether valid or not
which might directly or indirectly involve the company? If yes, please attach an explanation.
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA,
Page 5 of 6
NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN,
AND WYOMING APPLICANTS: In some states, 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, for the purpose of misleading, conceals information
concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for
the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any
insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: 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.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance 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.
NOTICE TO LOUISIANA APPLICANTS: 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 fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: 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.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 and the stated value
of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: 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.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an application
for insurance or statement of a 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 the person to criminal and civil penalties.
NOTICE TO TENNESSEE APPLICANTS: 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.
NOTICE TO VIRGINIA APPLICANTS: 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.
Page 6 of 6
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit
any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this
application and made a part of this application.
Applicant: Title:
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
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FIREARMS TRAINING SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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Completed 31 January 2021

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