Axe Throwing Quote Application

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 Information

Applicant*

Principal Contact First Name*

Principal Contact Last Name*

Mailing Address*

City*

State*

Zip Code*

My location address is different from my mailing address

My location address is different from my mailing address

Location Address*

County*

City*

State*

Zip Code*

Phone*

Fax

Email Address*

Website*

Type of business*

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 Information

Last Year

Insurance Carrier*

Limits of Liability*

Premium*

Two Years Ago

Same as Last Year

Same as Last Year

Insurance Carrier

Limits of Liability

Premium

Three Years Ago

Same as Last Year

Same as Last Year

Insurance Carrier

Limits of Liability

Premium

Additional Insureds - Please List Name, Mailing Address and Relationship

No Additional Insureds

No Additional Insureds

Additional Insureds:

Please include name, complete address and interest for each.

Producing Insurance Agent

Agency

Contact

Address

City

State

Zip

Phone

Fax

Email Address

THIS IS AN APPLICATION FOR INSURANCE. THIS IS NOT A BINDER OF INSURANCE.

Property Section

Location Information

Is 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 Operations

Estimated gross revenue for the next twelve (12) months*

Revenues from axe throwing ranges*

Revenues from sale of sporting goods*

Other revenue, describe:

Range Operations

Is 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 Supervision

Is 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 - Liquor

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

Max. file size: 256 MB.

Attach copy of applicant’s waiver, release of liability or assumption of risk form

Drop files here or

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 the Applicant allow "BYOB" on premises?*

Yes
No

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

Max. file size: 256 MB.

Name*

Title*

Must be signed by the President, Chairman, CEO, or Executive Director

Signature*

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.

Step 1 of 2

Submission Requirements

General Information

Prior Carrier Information

Additional Insureds - Please List Name, Mailing Address and Relationship

Producing Insurance Agent

Property Section

Retail Operations

Range Operations

Section IV - Liquor

Section to be Completed by the Producer/Broker/Agent