Fillable KINSALE GC Axe-Throwing-Supplemental-Application

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KINSALE GC Axe-Throwing-Supplemental-Application

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The KINSALE GC Axe-Throwing-Supplemental-Application form is 5 pages long and contains:

  • 1 signature
  • 18 check-boxes
  • 123 other fields

Country of origin: US
File type: PDF

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Page 1 of 5
AXE THROWING 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
3) What are your operations? Check all that apply:
Operation of Axe Throwing Lanes – Indoors – No Food or Drink
Operation of Axe Throwing Lanes – Outdoors – No Food or Drink
Operation/Rental of Mobile Axe Throwing Lanes
Operation of Axe Throwing Lanes – Indoors – With Food Service (no Alcoholic Beverages)
Operation of Axe Throwing Lanes – Outdoors – With Food Service (no Alcoholic Beverages)
Operation of Axe Throwing Lanes – Indoors – Including Alcoholic Beverages
Operation of Axe Throwing Lanes – Outdoors – Including Alcoholic Beverages
Hosting or Sponsorship of Axe Throwing Competitions/Sporting Events
4) What are your projected receipts for the coming year?
5) What is the approximate number of participants you will have this coming year?
GENERAL INFORMATION
Page 2 of 5
6) Is your operation compliant with any recognized standards (NATF, WATL, etc.)? Yes No
If Yes, list regulations/memberships.
7) Does your operation have any age restrictions? Yes No
If Yes, what age?
8) How many lanes does your operations have? Indicate indoor and outdoor if you are operating both:
9) What is the maximum distance axes are thrown?
10) How are throwing lanes separated from each other and from spectators? Please describe your lane construction:
11) Are written rules prominently displayed and reviewed with all participants before Yes No
axes are provided? Please provide a copy of your rules.
12) Do you have supervisors present at all times? Yes No
a. If yes, how many supervisors are on staff per shift?
b. What is the maximum number of lanes a supervisor will be observing at a time?
c. Are all supervisors first aid trained?
d. Please list certifications/training of supervisors:
13) Do you require signed waivers before any participation, training, or competition? Yes No
a. Please provide a copy of all waivers.
14) Do you offer axe throwing classes/training? Yes No
a. If yes, please list the certifications/qualifications of instructors:
b. How many students are instructed at a time?
15) Do you host any axe throwing sporting events or competitions? Yes No
a. If yes, how many annually?
b. How many participants per event?
c. How many non-participating attendees per event?
d. Are these events WATL or NATF official? Yes No
16) Do you have a Liquor License? Yes No
If yes, please provide license number:
17) Has your liquor license ever been revoked or suspended? Yes No
18) Do you carry separate Liquor Liability insurance? Yes No
If Yes, please provide carrier and policy number:
FOOD AND BEVERAGE SERVICE
Page 3 of 5
19) Have you experienced any liquor violations or claims in the last five years? Yes No
If yes, please attach details.
20) Do you have written guidelines for ID checking? Yes No
21) Are alcohol servers trained in documented, responsible alcohol serving techniques Yes No
(TIPS, TAM, RAMP, BEST, or similar)?
22) Do you have written policies against axe throwing while intoxicated for employees Yes No
and patrons that must be acknowledged before service? If yes, please attach a
copy of your policies.
23) Do you train employees on the handling of minors or intoxicated customers? Yes No
If yes, please provide details:
24) Are patrons or guest bartenders permitted to serve alcohol? Yes No
If yes, please clarify:
25) Do you allow “BYOB” consumption on premise? Yes No
26) Do you sell whole bottles of hard liquor to tables? Yes No
27) Please complete the following information regarding your sales:
Food ______ % of sales
Beer/Malt Beverages ______ % of sales; ______oz serving size; $______ average cost per drink
Wine ______ % of sales; ______oz serving size; $______ average cost per drink
Mixed Drinks ______ % of sales; ______oz serving size; $______ average cost per drink
Hard Liquor ______ % of sales; ______oz serving size; $______ average cost per drink
28) Do you end kitchen service before bar service? Yes No
If yes, by how many hours?
29) Do you run any of the following promotions:
a. “Happy Hour” reduced drink prices for 2 or more hours? Yes No
b. Any alcoholic beverages under $1? Yes No
c. Multiple drink incentives (i.e. “2 for 1,” “buy 3 get 1 free,” etc.)? Yes No
d. Complimentary drinks/reward drinks? Yes No
e. “All you can drink” specials? Yes No
30) Do you offer any of the following specialty food or drinks:
a. Flaming or ignited drinks or food? Yes No
b. Pitchers or “fishbowls” of wine, mixed drinks, or liquor? Yes No
c. Drinks or food involving dried ice or liquid nitrogen? Yes No
31) Do you permit employees to consume alcohol on premise either:
a. During work hours? Yes No
b. After shifts? Yes No
Page 4 of 5
32) Do you sell packaged goods for off-premises consumption? Yes No
33) Are persons under the age of 21 allowed on premises after 10:00 PM? Yes No
34) Do you provide any 3rd party transportation coordination (i.e. cabs, ride hailing apps, etc.)? Yes No
35) 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.
36) 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,
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.
ACCOUNT HISTORY
Page 5 of 5
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.
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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KINSALE GC Axe-Throwing-Supplemental-Application

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Completed 2 July 2020

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