Fillable SHOOTING RANGE SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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SHOOTING RANGE SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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The SHOOTING RANGE SUPPLEMENTAL APPLICATION (Kinsale Insurance) form is 6 pages long and contains:

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  • 21 check-boxes
  • 190 other fields

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Page 1 of 6
SHOOTING RANGE 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) Detailed diagram of lanes and ballistic paneling/backstops; ventilation equipment (for indoor ranges)
3) What are your operations? Check all that apply:
Shooting Range – Public – Indoors
Shooting Range – Public – Outdoors
Shooting Range – Private/Gun Club – Indoors
Shooting Range – Private/Gun Club – Outdoors
Shooting Range – Law Enforcement/Military Only – Indoors
Shooting Range – Law Enforcement/Military Only – Outdoors
Firearm Obstacle Course – Soft Round, Airsoft, Paint or other Marker
Firearm Obstacle Course – Live Fire Ammunition
Firearm Amusement Center – No Aircraft, Tank, or Military Vehicle
Firearm Amusement Center – No Aircraft – Utilizing Tanks or Military Vehicles
Firearm Amusement Center – Utilizing Aircraft
Explosives Range or Fireworks Launching Site
Firearms Training Site – Firearms Safety – Instructed by You or On Your Behalf (please complete Kinsale Firearm Instructor App)
Firearms Training Site – Firearms Safety – Instructed by Others/Private Instructors
Firearms Training Site – Tactical Use – Instructed by You or On Your Behalf (please complete Kinsale Firearm Instructor App)
Firearms Training Site – Tactical Use – Instructed by Others/Private Instructors
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 6
4) What are your projected receipts for the coming year? $
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, organized crime, and “straw sales” violations 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) 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
13) Do you sell any products? Yes No
a. If yes, do you sell firearms? Yes No
b. Ammunition? Yes No
c. Personal protective equipment? Yes No
d. Ballistic armor? Yes No
e. Other:
14) Please indicate the personal protective equipment required on the range:
a. Ear Protection? Yes No
b. Eye Protection? Yes No
d. Other : Yes No
15) How many lanes do you have?
a. How many people may occupy a lane?
b. How many range safety officers are present at all times?
16) Do you require new shooters to attend a range safety presentation? Yes No
a. If yes, do you require periodic reviews of the range safety presentation? Yes No
b. How often?
Page 3 of 6
17) Do you rent firearms? Yes No
a. If yes, do you rent any Title II/NFA firearms? Yes No
b. Do you allow new shooters to rent firearms? Yes No
c. If yes to b., are new shooters who arrive solo allowed to rent? Yes No
d. How frequently are rented firearms cleaned and inspected?
18) Do you allow the use of Title II/NFA firearms at the range? Yes No
19) Do you have any restrictions on the types of ammunition allowed on the range? Yes No
a. Do you require that shooters use ammunition purchased at the range? Yes No
b. Do you allow the use of any incendiary, “dragon’s breath”, or explosive rounds? Yes No
c. Do you allow the use of any armor piercing rounds? Yes No
20) If you operate any outdoor ranges, please complete the following:
a. Do you allow shooting before sunrise or after sunset? Yes No
b. If yes, please describe range lighting:
c. Do you allow the use of binary composite, sparking, or explosive targets? If yes, please Yes No
complete the Explosives Ranges or Fireworks Launching Sites section of this application.
d. Do you have any skeet, clay pigeon, clay target, or similar shooting? Yes No
e. If yes to d., how many shooters are permitted to fire each pull?
21) Do you allow shooting from any position other than forward facing upright, seated, or prone? Yes No
a. If yes, please clarify:
b. Do you require shooters to keep both hands on their firearm while shooting? Yes No
22) If your range is used as a firearms training site, please complete the following:
a. If instruction is privately coordinated/not conducted by you or on your behalf, do you Yes No
require instructors to provide proof of insurance?
b. Do you require all instructors to be certified, regardless of any state or local requirements? Yes No
23) Are your courses limited to law enforcement, licensed private security, or military personnel only? Yes No
a. If no and you allow live fire, do you have a mandatory minimum proficiency exam Yes No
before course participation?
b. What is the minimum accuracy threshold? %
24) How many participants may be on the course at one time?
25) Is any bodily contact made with course participants at any point in the course? Yes No
a. If yes, is this contact made by another person? Yes No
b. Does any bodily contact involve the use of electroshock devices or chemical irritants Yes No
(such as Taser or pepper spray devices)?
26) Do any courses involve the use of climbing or rappelling? Yes No
27) Do any courses involve low light or vision obstruction (nighttime, smoke, strobing lights, etc.)? Yes No
28) Are in-person observers allowed on course location during runs? Yes No
a. If yes, how are observers protected from projectiles?
b. Are observers limited to adults 18 (eighteen) years of age or older? Yes No
Page 4 of 6
29) Do any courses utilize fire, pyrotechnics, or explosives? Yes No
30) Do any courses utilize other environmental hazards (intense wind, rainfall, noxious odors, etc.)? Yes No
31) Is the ground or flooring of all courses firm and non-skid in all areas where the participant may Yes No
discharge their weapon?
32) Do you allow participants to shoot fully automatic firearms that are not mounted to a bench, Yes No
vehicle, seat, or other fixture?
a. If yes, are participants required to be over 21 (twenty-one) years of age or over 16 Yes No
(sixteen) years of age and accompanied by a parent or guardian over the age of 25
(twenty-five)?
b. Height and weight minimums, if applicable:
c. What is the largest caliber arm that can be shot from an unmounted fully automatic weapon?
33) 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 tanks? Yes No
d. If yes to c., is the tank cannon operational and intended to be fired by participants? Yes No
e. If yes to d., what type of round is fired?
34) 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
35) How frequently are firearms cleaned and inspected?
36) What type(s) of explosive do you allow to be used at your facility? Attach additional pages if needed:
37) Do you require clients to have an explosives permit or special licensing to use your facilities? Yes No
38) Is your facility a testing facility/professional use only?
39) Do you sell or provide explosives or fireworks? Yes No
a. If yes, please describe:
b. How are explosives stored and secured when not in use?
40) What is the maximum yield you allow to be detonated at your site?
Page 5 of 6
41) What detonation methods do you permit:
a. Lit fuse ? Yes No
b. Pin and lever fuse/thrown? Yes No
c. Timer? Yes No
d. Pressure or wire tripped? Yes No
e. Gunshot/explosive target? Yes No
f. Radio/remote? Yes No
42) 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.
43) 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.
Page 6 of 6
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.
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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SHOOTING RANGE SUPPLEMENTAL APPLICATION (Kinsale Insurance)

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Completed 31 January 2021

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