Escape Rooms Quote Application

Applicant Information

Insured Name*

Mailing Address

Street*

City*

State*

Zip Code*

Event Name/Address

Street*

City*

State*

Zip Code*

Website Address*

Applicant is*

Contact First Name*

Contact Last Name*

Phone*

Fax

Email Address*

Event Information

Event Description:*

Attach any promotional material

Drop files here or

Max. file size: 256 MB.

Date Business Established*

Effective Date*

End Date*

Estimated Attendance*

Last Year's Attendance*

Max Number of Players*

Price of Admission*

Estimated Gross Attraction Receipts*

Estimated Gross Attraction Receipts (Estimated Attendance x Price of Admission)

Estimated Food Receipts*

Estimated Merchandise Receipts*

Attendee Age Range*

Minimum Age*

Special Concerns for Children*

Monitoring Room Square Footage*

Crowd Control/Security*

Yes
No

If using hired security, are certificates of insurance obtained?*

Yes
No
N/A

Are first aid facilities provided?*

Yes
No

Describe:*

Employee Type and Numbers*

Regular*

Leased*

Volunteer*

Is Workers' Compensation Coverage in Force?*

Yes
No

Estimated Payroll*

Are food and beverages sold on the premises?*

Yes
No

Outside vendor?*

Yes
No

Food types available*

Cooking methods if cooked on site*

Alcoholic beverages served*

Live Actor(s) in Room*

Yes
No

Are Escape Rooms locked*

Yes
No

How do patrons get out in emergency?*

Fire Extinguishers on site*

Yes
No

Fire Extinguishers Must Have Valid Inspection Tag

Smoke Detectors*

Yes
No

Sprinkler System*

Yes
No

Completed Fire Dept. Inspection*

Yes
No

Certificate of Occupancy*

Yes
No

Number of Rooms*

Room Dimensions (in feet)*

Length of Game*

45 min
60 min

Special Effects and Devices:*

Applicant History

Describe applicant’s experience with escape rooms including years, number, and dates:*

Premium and Loss Record for the Last Five Years

Premium and Loss Record for the Last 3 Years:*

For each year, please list policy period, carrier, premium, loss amount, and non-renewal or cancel.

Please attach Loss Runs from your prior Insurance Carrier(s), for the past 3 years. If this is your first year in business, please disregard. If you have been with Donat Insurance Services, LLC, for the past 3 years, please disregard.

Drop files here or

Max. file size: 256 MB.

Describe details of losses/incidents for the past 3 years:

Any additional Insureds being requested?*

Yes
No

Provide Name, Address and Relation:*

Would you like Property Coverage?*

Yes
No

Limit?*

Building Coverage: Limit?*

Contents Coverage: Limit?*

Would you like Business Interruption Coverage?*

Yes
No

Limit?*

Insurance Coverage will be written with limits of $1,000,000 per occurrence and an annual aggregate of $2,000,000. The Insured represents that the information contained in this application is accurate and that it shall be the basis of the policy of insurance. The Insured further represents that it has not withheld any information which would have affected the company’s decision to offer coverage. If the insured has withheld any such information with intent to defraud or give false information to the company, the Insured understands that its coverage may be voided. The Insured further understands that its failure to disclose any information in its possession, which may lead to a claim, will relieve the insurance company of any obligation under the policy.

Insured 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: The indication of interest above, is for purposes of obtaining a quotation for coverage only and does not result in coverage without further application and payment of additional premium.