Axe Throwing Quote ApplicationPlease answer the following questions to the best of your ability. We understand that these are estimates. If you have questions, please call us at (641) 585-0510. Step 1 of 2 50% Submission Requirements All brochures describing any and all services; or website address. The liability waiver / hold harmless agreement you require your guests to sign, if applicable. Currently valued insurance company loss runs for the current policy period plus 3 prior years. If unavailable, provide a no loss letter signed by the insured. ACORD forms for other lines requested (Property, Inland Marine, Crime, etc.) General InformationApplicant* Principal Contact First Name* Principal Contact Last Name* Mailing Address* City* State*StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code* My location address is different from my mailing address My location address is different from my mailing address Location Address* County* City* State*StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code* Phone*FaxEmail Address* Website* Type of business* Individual Corporation Partnership LLC Date Business Established* Effective Date* Risk Management Contact* Risk Management Phone*Risk Management Email* Does the Applicant operate any other business from this location?* Yes No (List information below for each business)Type of entity* Corporation Partnership Individual LLC Other Description of business:*Does the applicant have separate insurance for this business?* Yes No Prior Carrier InformationLast YearInsurance Carrier* Limits of Liability*Premium*Two Years AgoSame as Last Year Same as Last Year Insurance Carrier Limits of LiabilityPremiumThree Years AgoSame as Last Year Same as Last Year Insurance Carrier Limits of LiabilityPremiumAdditional Insureds - Please List Name, Mailing Address and RelationshipNo Additional Insureds No Additional Insureds Additional Insureds:Please include name, complete address and interest for each.Producing Insurance AgentAgency Contact Address City StateStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip PhoneFaxEmail Address THIS IS AN APPLICATION FOR INSURANCE. THIS IS NOT A BINDER OF INSURANCE.Property SectionLocation InformationIs the building* Owned Leased Fire Alarm* Yes No Central or Local* Central Local Burglar Alarm* Yes No Is the alarm UL listed or approved?* Yes No Central or Local* Central Local Smoke Detectors* Yes No Battery or Hardwired* Battery Hardwired Doors are* Metal Glass Frame Do windows and glass doors have metal bars?* Yes No Describe other protection (safe, dead bolt locks, metal bars, crash barriers in front of building, fire extinguishers, etc.):*If the Applicant's building is more than ten (10) years old, what year was the last time wiring, plumbing and heating/AC were updated and/or serviced?:*Does the building have other occupancies?* Yes No Describe:*Are there any additional locations to be covered?* Yes No Please provide complete address and describe:*Are all activities and locations to be covered in full compliance with applicable federal, state and local regulations?* Yes No Is the building within city limits?* Yes No Is the building 100% sprinklered?* Yes No What is the distance to the nearest fire hydrant?*Other activities conducted on the premises:*Retail OperationsEstimated gross revenue for the next twelve (12) months*Revenues from axe throwing ranges*Revenues from sale of sporting goods*Other revenue, describe:Range OperationsIs the range in compliance with any recognized standards? (i.e., NATF, WATL)* Yes No Does the range have any age restrictions?* Yes No Please describe:* Indoor Range?* Yes No Number of Lanes* Outdoor Range?* Yes No Number of Lanes/Stations* Max. Distance Thrown* Axe Throwing* Yes No Is there a supervisor on duty at all times?* Yes No Are supervisors first aid certified?* Yes No Are waivers mandatory?* Yes No Please provide a copy*Max. file size: 256 MB.Reason why No:* Range SupervisionIs a supervisor on duty at all times?* Yes No Number of range supervisors* Max ratio of supervisors to lanes* Type of certification of range supervisors* Does the Applicant have written rules prominently displayed?* Yes No Does the Applicant provide lessons?* Yes No Provide qualifications of instructors:* Number of annual participants:* Section IV - LiquorDoes the Applicant allow "BYOB" on premises?* Yes No Does the Applicant sell alcohol?* Yes No Does the Applicant currently have liquor liability insurance?* Yes No Please provide licensee name/number/state* If liquor liability insurance needed, a separate application is required.Please attach Loss Runs from your prior Insurance Carrier(s), for the past 5 years. If this is your first year in business, please disregard. If you have been with Donat Insurance Services, LLC, for the past 5 years, please disregard. Drop files here or Select files Max. file size: 256 MB. Attach copy of applicant’s waiver, release of liability or assumption of risk form Drop files here or Select files Max. file size: 256 MB. Has the Applicant or any owner ever had a liquor license revoked or suspended?* Yes No Please explain:* Has the Applicant had any violations or claims in the last 5 years?* Yes No Please explain:* Are patrons or guest bartenders allowed to serve alcohol?* Yes No Please explain:* Does the Applicant sell whole bottles of hard liquor to tables?* Yes No Does the Applicant have written guidelines for checking ID?* Yes No Are alcohol servers trained in documented, responsible alcohol serving techniques (i.e., TIPS, TAM, RAMP, BEST, etc.)?* Yes No Is any training provided for servers in handling of minors or intoxicated customers?* Yes No Please explain:* Does Applicant have current Liquor Liability policy?* Yes No Average cost of beer*Average cost of wine*Average cost of wine bottle*Average cost of mixed drinks*Average size of glasses/cups (oz)* Does the Applicant run or plan to run the following alcohol promotions:a. Reduced drink prices for more than 2 hours?* Yes No b. Any prices reduced to $1.00 or less?* Yes No c. Multiple drink incentives (i.e., 2 for 1, every 3rd drink is free, etc.)?* Yes No d. Complimentary drinks or "all you can drink" specials (other than banquets, some rentals)?* Yes No Does the Applicant offer flaming or ignited drinks?* Yes No Does the Applicant ever permit employees who serve liquor to consume alcohol on the job?* Yes No Does the Applicant ever permit employees who serve liquor to consume alcohol after shifts?* Yes No Does the Applicant sell packaged goods for off-premises consumption?* Yes No Are persons under the legal drinking age allowed on premises after 10 p.m.?* Yes No Does the Applicant provide 3rd party transportation (i.e., cabs)?* Yes No FRAUD STATEMENT AND SIGNATURE SECTIONS The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the quote or binder. The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy. *Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company. VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED, MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.FRAUD NOTICE STATEMENTS 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 AND SUBJECTS THAT PERSON TO CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS ($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, PA, RI, TN, VA, VT, WA AND WV). APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON. APPLICABLE IN COLORADO: 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 POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES. APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE). APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO. APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: 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 A DENIAL OF INSURANCE BENEFITS. APPLICABLE IN PENNSYLVANIA: 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. APPLICABLE IN NEW YORK: 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 BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.Liability waiver or hold harmless agreement you require your guests to sign.* Drop files here or Select files Max. file size: 256 MB. Name* Title* Must be signed by the President, Chairman, CEO, or Executive DirectorSignature* Date* Electronic Signature Agreement* By checking this box I acknowledge that the information I have entered is accurate and understand that the field above constitutes as my electronic signature. Revenue Audit* I understand that written policies are subject to audit.We understand both the attendance and receipt values are estimated values. With that, we strongly encourage you to give the most accurate estimate as possible. By doing so, it allows us to provide you with a quote that is as reflective of your needs as possible. In addition, all policies are subject to an audit upon expiration. Therefore, providing the most realistic estimate as possible, not only allows us to provide the most accurate quote, but will also aide in reducing the possibility of a large discrepancy in these estimates when audited, which could potentially result in additional premium charges.Please Note: This General Liability policy does not provide coverage for Liquor Liability. If you are interested in Liquor Liability coverage, please contact our office at Quotes@DonatInsurance.com. The indication of interest is for the purpose of obtaining a quotation for coverage only and does not result in coverage without further application and payment of additional premium. Please review all the following fields to ensure your information is accurate, then scroll down to the bottom of the page and click "SUBMIT".{all_fields}Section to be Completed by the Producer/Broker/AgentProducer (If this is a Florida Risk, Producer means Florida Licensed Agent)Agency Producer License Number (If this is a Florida Risk, Producer means Florida Licensed Agent)Address (Street, City, State, Zip) CAPTCHA