OUTDOOR SPORTS AND RECREATION INSURANCE



YOUR AGENCY INFORMATIONAgency Name: ___________________________________________________Address: _________________________ City: __________________ State:________ Zip: ________Contact Name: ________________________ Phone: _____________________Email: _______________________________________________INSURED INFORMATIONNamed Insured/ DBA: ___________________________________________________________Legal Name of Company: _________________________________________________________Primary contact person: ____________________________ Phone: (______) _______________Email: ___________________________________ Fax Number: ________________________Mailing Address: _______________________________________________________________City: _________________ CountyCOUNTY__________________ State: ___________ Zip: __________Website: _____________________________________________________________________APPLICATION DIRECTIONS (TO MAKE THIS COMPREHENSIVE SUPPLEMENTAL EASIER)Please read through each sSection of this Application Form, then complete oOnly the sSections for which the applicant has exposures.ANY INQUIRY OR STATEMENT THAT NEEDS AN EXPLANATION OR ADDITIONAL INFORMATION, USE THE SPACE PROVIDED OR, ADD NOTES IN THE “ADDITIONAL INFORMATION” SECTION, USING THE LINE NUMBER IN THE LEFT MARGIN AS THE REFERENCE.KEEP THIS APPLICATION INTACT AND RETURN ALL SECTIONS, EVEN IF NOT NEEDED.ALSO PREPARE THE FOLLOWING ACORDS AS NEEDED: ACORD 125, ACORD 126, ACORD 130, & ACORD 131*Every submission MUST include the Acord 125 & 126**The Acord 130 & 131 are on an as needed basis*INSURANCE PROGRAM SUPPLEMENTAL APPLICATION (OR INDUSTRY EQUIVALENT) TO BE COMPLETED IN ADDITION TO RELEVENT ACORD FORMSNote to Agents: The more OSR knows about the business and its operations, the better we can provide you with accurate and appropriate quotes in a much shorter turnaround time. We respect your professional needs, and we thank you for respecting ours.Your extra work to fully complete this application enables us to better serve you with the best value. No answers to applicable inquiries will result in higher premiums and slower return, or even rejection of this submission. You choose your level of success.Questions/discussions or inquiries on any part: SUBMISSIONS@CLASSIFY THE APPLICANT OPERATIONS: PRIMARY AND ANCILLARYMark each of the following as either: “Primary” “P” aspects of the business,Or an “Ancillary” operation “A”, or “Not in that business” “N”:OPERATION/ACTIVITYKEY COMPONENT P, A or NISO GLRifle/Pistol Shooting RangeIndoor47253Outdoor47254Archery RangesIndoor10052Outdoor10054RETAIL GUNS & ACCESSORIESSporting goods stores18206Apparel/Accessories11127INSTRUCTIONClassroom47253RENTALSporting goods (NOT RANGE)47253GUNSMITH95620HUNTINGHunting clubs45224Hunting preserves 45225LODGING B&B, Lodges45192GUIDESGuides/Outfitters44222MANUFACTURINGLimited accessories and small-arms ammo only *51211FOOD SERVICESRestaurant/CafeLIQUOR LIABILITYServe at LocationTake OutPLEASE MARK THIS “SECTION CHECKLIST” TO MATCH OPERATIONSALL APPLICATIONS PROVIDE # 1 AND # 14Check if includedSECTION 1GENERAL OPERATIONSSECTION 2LOCATION INFORMATION -USE ONE FOR EACH LOCATIONSECTION 3BUILDING DETAILS—USE ONE FOR EACH BUILDINGSECTION 4RETAIL OPERATIONSSECTION 5RANGE OPERATIONS (Firearms, Archery, Skeet)SECTION 6GUNSMITH OPERATIONSSECTION 7AUTOMATIC FIREARMS (NFA) SALE OR RENTAL SECTI0N 8BLACK POWDER/SMOKELESS POWDERSECTION9HUNTING LODGES/PRESERVESSECTION10GUIDES/OUTFITTERSSECTION11MANUFACTURINGSECTION12EMPLOYEE BENEFITS LIABILITY OPTION (EBL)SECTION13EMPLOYMENT RELATED PRACTICES (EPLI) LIABILITY OPTIONSECTION14CYBER LIABILITY OPTIONSECTION15EVERY APPLICATION REQUIRED ITEMSSECTION16ADDITIONAL INFORMATION EXTENSION ADDENDA, RESOURCES FOR AGENTS/APPLICANTSProposed Effective Date: __________ Quote needed by: ______________ Application Date: _______________SEND QUOTES AND CONVERSATIONS TO: _______________________________ AT ___________________________SECTION 1 GENERAL OPERATIONS/MANAGEMENT QUESTIONS (All Applicants)IF MULTIPLE LOCATIONS, CHECK HERE COMPLETE ACORD 140 AND OUR SECTION 2 FOR EACH LOCATION. LOCATION ADRESS: ___________________________________________City: ______________________ County: ____________ State: ___________ Zip: _________Entity Form: Corporation ___ Partnership ___ Individual ____ LLC ___ Other: _____________Number of years in business. If new venture, how many years of experience? ____________CURRENT INSURANCE INFORMATION:COMPANY/CARRIER NAME(NOT AGENT, BROKER, PROGRAM)TYPE OF COVERAGE (LINE OF BUSINESS)EXPIRATION DATEBROKER/AGENT: ______________________________________________________________________Has insurance coverage been canceled or non-renewed within the past three years? (Missouri applicants need not respond). YES NO If yes, please explain: _____________________________________________________________________________________LOSSES: IF NONE CHECK HERE Otherwise, describe all property losses within the past 5 five years including dates, amounts, types of loss, whether paid or not. Indicate additional safeguard and/or improvements to prevent similar losses. Add additional info in REMARKS to explain. THIS SECTION FOR UNDERWRITING INFORMATION. *FINAL RATES WILL BE BASED ON CURRENTLY VALUED LOSS RUNS*EVENT DATEDESCRIPTION OF INCIDENT/LOSSAMOUNT PAIDAMOUNT RESERVED$$$OSAR USEINSURANCE HISTORY OVERVIEW:Property Insurance Information Insurance CarrierLimits of LiabilityPremiumPrior year$$Two years prior$$Three years prior$$Four years prior$$LIABILITY INSURANCEInsurance CarrierLimits of CoveragePremiumPrior year$$Two years prior$$Three years prior$$Four years prior$$UMBRELLA/EXCESS INSURANCE INFORMATIONInsurance CarrierLimits of LiabilityPremiumPrior year$$Two years prior$$Three years prior$$Four years prior$$WORKERS COMPENSATION INSURANCE INFORMATIONInsurance CarrierLimits of LiabilityPremiumPrior year$$Two years prior$$Three years prior$$Four years prior$$OTHER LINES (EPLI, Cyber, EBL) INSURANCE INFORMATIONInsurance CarrierLimits of LiabilityPremiumPrior year$$Two years prior$$Three years prior$$Four years prior$$Is club/ organization membership required? YES NO If yes, please provide copy of membership agreements.List all Federal Firearm Licenses applicant holds and included copies of each:Class _______ _________ _________ (IF YOU HAVE A CLASS 6 or 7 FFL, YOU ARE REQUIRED TO COMPLETE SECTION 11 (for Manufacturing)Does Applicant operate any other business (s) from ANY location? YES NO If yes, please List Name and Description of other business(s): _______________________________________________________________________________________________________Does Applicant have separate insurance for the other business(s)? YES NO If yes, please provide detail: ________________________________________________________ Are there written safety policies, procedures, and rules for shooters? YES NO N/AGROSS REVENUE: Past 12 months $_______________ Projected next 12 months: _______________Does Applicant present or display any products/services at gun shows? YES NO Does Applicant sell products to any entity that requires Applicant to name them as an Additional Insured? YES NO Does Applicant have any contracts or lease agreements that require Applicant to name another party as an Additional Insured? YES NO ADDITIONAL INSURED INFORMATION NAMECOMPLETE ADDRESSINTEREST/REASON FOR A.I.Does Applicant offer any warranties on any products Applicant’s company makes or modifies? YES NO Does Applicant sell any products that extend beyond the manufacturer’s warranty period? YES NO Does Applicant sell any products that have an enhanced or expanded warranty? YES NO Describe security camera and alarm system for facility: _____________________________________Does Applicant have pawn operations? YES NO REGULATORY INFORMATION:Is Applicant requesting “Regulatory Entity Defense Coverage” (ATF Hearing)? YES NO What was the date of Applicant’s last ATF inspection? ___________________ Were there any ATF violations cited? YES NO If yes, please describe the citation(s) and the resolution: ________________________________________________________________________________________________________________Has Applicant ever experienced any corrective action from an Environmental/EPA or Occupational/OSHA entity? YES NO If yes, please describe the citation(s) and the resolution, including dates: Name:_________________________Phone#:_____________________Email:____________________Please list name and contact of the person responsible for compliance management:______________________________________________________________________Are all activities and locations to be covered in full compliance with applicable federal, state, and local regulations? YES NO PRIVACY AND SAFETY OF PERSONAL /PRIVATE INFORMATIONDoes Applicant use an integrated Point of Sale system? YES NO If yes, please name vendor & system used:______________________________________________________________________________Does Point of Sale or data storage system use encryption technology? YES NO Who (roles, not names) has access to customers’ private/personal information __________________Applicant steps to protect customer personal data include: _____________________________________________________________________________________________________________________EMPLOYEE/STAFF INFORMATION:Number of Employees: FULL TIME: ______ PART TIME: ______ (FT= 32 hours/more per week)PAYROLL: Past 12 months: $ _____________ Projected Payroll next 12 months: $________________Does Applicant hire/use contract workers for any operations, including instructors? YES NO If yes, what is the total number of contract workers used? _____________________What is the total annual premium paid to contract workers? ____________________Does Applicant involve volunteers in any business operations? YES NO Does Applicant conduct background checks/investigations on all new employees? YES NO Describe the method and steps used, to conduct employee checks: ______________________________________________________________________________________________________Does Applicant conduct benchmark testing for: Hearing YES NO Blood (lead, toxins, substances) YES NO Are there written safety and return to work policies, procedures, and rules for staff/employees? YES NO Does Applicant maintain “drug free workplace” standards? YES NO Does Applicant provide state sanctioned drug free workplace programs to all employees? YES NO If yes, how often? _______________________________________________________________Are your employees versed in Federal, State, and Local Laws regarding the distribution of guns, ammunition and/or gunpowder (black or smokeless)? YES NO Does Applicant or employees hold any special certifications or training? YES NO If yes, please describe: ____________________________________________________________Are all employees trained and monitored in the detection of “Straw Sales” aka “Will not lie for another to buy”? ( ) YES NO Number of employees who may at any time use their personal autos in applicant’s operations. _______Does Hired/Non-Owned auto use ever include transporting hazardous materials or firearms? YES NO Does applicant obtain driver history (MVR) and evidence of employees’ insurance (for applicable employees)? YES NO Have all Officers, contract persons, and employees acknowledged they understand Form 4473, regarding Straw Sales, and all other federal and local laws concerning the sale of firearms, ammunition, black and smokeless powder? YES NO Section 2-PER LOCATION INFO -ONE SECTION PER LOCATION (EXTRAS @ END) Wherever limits of coverage are requested, please provide the total values at current Replacement Costs. (Costs to replace new, with materials of like quality and kind, not market Value)Location Information for LOCATION # _____ of ______ MULTIPLE BUILDINGS AT ONE LOCATION?MULTIPLE LOCATIONS? MULTIPLE BUILDINGS? USE OUR STATEMENT OF VALUES TOOLHELP BY MAKING A QUICK ‘SITE MAP’ FROM SATELLITE SHOT AND LABEL THEM TO MATCH YOUR SUBMISSIONWhat are the applicant’s hours of operation (AM to PM)?SUNDAYMONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAYSATURDAYRANGERETAILOTHERAre there any cooking or food service activities at this location? YES NO If yes, please explain:___________________________________________________________If located in a coastal state, how many miles to the nearest coastal waters? _______________Location safety and security:Is there a watchman/security service on premises? YES NO Fire Alarm: YES NO Central ____ Local ___ Battery backup____Intrusion Alarm: YES NO Central ___ Local ___ Battery backup ____Monitored by (entity) ____________________Smoke Detectors: YES NO Battery ______ Hardwired ______ Tied to Central? ______Describe your camera/visual monitoring systems:Doors are: ______ Metal ______Glass_____FrameDo windows doors have metal bars or secondary protections (i.e; roll doors, bar grids)? YES NO If yes, please explain what is used: _______________________________________________________Describe gun safe storage manufacturer, type, class, (listed on the label on safe door)? ___________________________________________________________________________________Describe other protection: (Safe, dead bolt locks, metal bars, crash barriers in front of building, fire extinguishers, etc.)____________________________________________________________________________________Does this location have other occupancies? YES NO If yes, please describe: ___________________________________________________________Does Applicant have standby /emergency power generating equipment? YES NO If yes, is it 100% for emergency use only? YES NO List the size of each unit (in HP and KW): ___________________________________________Are there procedures in place for staff to help with building evacuation in emergency situations? YES NO Please elaborate on those: ________________________________________________________ _______________________________________________________________________________ SECTION 3 BUILDING information Details—ONE PER BUILDING (EXTRAS @ END)LOCATION # ____ BUILDING # ______PHYSICAL ADDRESS IS: ____________________________________________________ City _________________ County __________________ST __________ Zip ____________Construction TYPE: ____ FRAME metal/wood______ Joisted Masonry _____ Tilt up concrete _____ Masonry Non-Combustible ______Modified Fire Resistive _________Fire ResistiveYear built: _______ Roof Surface (all that apply): TPO Built UP Metal Shingles Other: __________Roof pitch/grade (all that apply): FLAT PITCH: 0-4 5-12 OVER 12Roof style (all that apply): GABLE SLOPE DORMER HIP Age of Roof (years) _______________Date of last upgrades: Roof_____ Electrical_____Plumbing______HVAC_______OTHER___________________________________________________________________________If building is more than ten (10) years old describe maintenance of services: _________________________________________________________________________________Number of floor(s): ______ Square feet per floor______ Basement square footage: ________Total building area: ______________ Total area occupied ________ square ft Distance to nearest structure (in feet): _________The neighborhood setting is (left, right, front, rear structures) _______________________________________________________________________________Has this building been converted to present use from a different past use? YES NO Security Cameras _________ local ________ monitored service _____internet platform? Distance to nearest hydrant? __________________If none, please describe the water source in the area: ________________________________Distance to & Name of nearest Fire Department: __________________________________________Paid _____ Volunteer ______Within city limits? YES NO Fire District? YES NO ISO Protection Class (please circle) 1 2 3 4 5 6 7 8 9 10Does building have a sprinkler system? YES NO If yes, what ______ % or ______ square feet Add sprinkler leakage coverage? YES NO Date of last sprinkler test: __________________ Have all fire extinguishers /suppression systems been professionally inspected and tagged within the last year? YES NO Are fire extinguishers/sprinklers/suppression checked and signed each 30 days or less? YES NO Is the building free standing? YES NO Does building have lighted ‘exit’ signs, with emergency exit lighting? YES NO Does the Applicant lease or own building(s): __________ Number of Mortgages: ________Name and address of Mortgagee: ______________________________________________________________________________Name and address of Loss Payee: ______________________________________________________________________________If TENANT, does lease require Applicant to insure the Improvements & Betterments? YES NO If so, advise the “I & B” Replacement Cost? ___________________Does Leaseholder require they be named as Additional Insured? YES NO Are there any other tenants in the building? YES NO If yes, please describe____________________________________________________________IF other tenants/neighbors in the same structure, describe the fire separations that are in place: _________________________________________________________________________________________Neighboring attached occupancies: Left_________ Right_________ Rear________ Front ________Provide details of Applicant’s air handling/filtration systems:Is there “Positive” (downrange) airflow in all shooting/gunsmith areas? YES NOAmount of Building Coverage from your Insured Valuation Tool (include please):Building: $_________________ (please circle) RCV ACV Coinsurance (please circle): 80% 90% 100% Deductible $ ____________TOTAL value of Business Personal Property: FF&E, Inventory, Stock, etc. $ _________________Show details of the BPP in the respective Section(s) and enter total for this BUILDING HERE. LOSS OF BUSINESS INCOME/EXTRA EXPENSE $___________________(USE OUR WORKSHEET-IT HELPS!) Coinsurance TIME ELEMENT: ________ or DEDUCTIBLE: ____________Business Income planning: Annual Gross Sales Less Cost of Goods Sold and Expense that do not continue while your business is closed due to a covered loss. (Or Net Profit + Continuing Expenses). ___________EQUIPMENT BREAKDOWN COVERAGE Include? ______ Exclude? _______a. Certification: SAAMI, ANSI, ISO? YES NO b. Maintenance contract? __________With whom? ____________________________________c. Deductible: 1000_____2,500_____5,000____10,000____d. Are any boilers or ‘pressure vessels’ in use at the facility (includes air compressors, pressurized tanks)? YES NO If yes, please explain: ______________________________________Are CHLOROFLUOROCARBON (CFC) REFRIGERANTS used in the machinery? YES NO Are all equipment devices maintained in accordance with manufacturers recommendations: YES NO Signs: $_____________ Please describe (monument/street/on building, etc.) ____________________________________________________________________________________________________________________________________________________________________If signs are not attached to the building, how far from the building are the signs located? ___________SECTION 4 RETAIL: FIREARMS/ AMMO/OTHER RETAIL_______Please Quote _______None At This TimeDoes Applicant sell ammunition with Applicant’s label or brand manufactured by another entity? YES NO If yes, does the manufacturer provide a “Vendors Endorsement” liability insurance with Applicant as an Additional Insured? YES NO Does Applicant sell at gun shows? YES NO If yes, what percentage of sales are at gun shows? Products: Ammo/Firearms/Other _________%If yes, does Applicant complete a Form 4473 and NICS Background Check for each buyer? YES NO Does Applicant sell any products through the internet? YES NO If yes, what is the percentage of total sales? _________% If yes, does Applicant have procedures in place to address state specific laws/regulations related to all sales? YES NO List all states, jurisdictions that you will NOT ship to: ______________________Does Applicant ship any products to licensed FFL Dealers? YES NO If yes, does Applicant obtain and keep a copy of that FFL Dealer’s License? YES NO Are all your firearm/ammunition products purchased from U.S. manufacturers or distributors? YES ___If no, ________ % are directly imported by you from foreign companiesIf no, ________ % are purchased from foreign wholesalers/distributorsDoes Applicant provide a written owner’s manual, warning and safety instructions with each firearm that is sold? YES NO Please share how firearms are secured during business hours to prevent theft? __________________________________________________________________________________After business hours: _________________________________________________________________If not secured, describe additional safeguards taken against ‘Smash & Grab’: ________________________________________________________________________________________________________What system does Applicant use for Inventory Management? ________________________________Does Applicant sell or provide hand loaded ammunition? YES NO Does Applicant sell Automatic (NFA) firearms and accessories? YES NO Does Applicant participate in ammunition manufacturing, importing or reloading operations? YES NO If yes, what is the % of sales? ____________If Applicant is a wholesaler or distributor, is Applicant named on manufacturer’s or importer’s insurance policy of vendor’s liability coverage? YES NO *If yes, please provide a copy of the endorsement*Does Applicant provide any gunsmith operations? YES NO If yes, please complete SECTION 6 on Gunsmith OperationsWhat is the total value of (non-firearms) retail inventory at this building? $______________________What is the total value of firearms inventory at this building? $______________________Finished Goods: Total Value held for sale--NOT Retail Value: $______________________Please provide the average number of firearms in your inventory as well as values detail below. Or, enter in “Range” Section: Business Personal Property Consists of: ValuesLong guns $# NEW IS: # USED IS:Hand guns$# NEW IS: # USED IS:Gun parts$Ammunition$Powder$Sporting goods$Property in Transit $From gun shows/vendorsProperty off-campus$Displays/at gun showsFurniture/fixtures$Stock/ Other Retail items$Range Machinery/Equipment$Other Machinery /Equipment$Total Limit of BBP: $______________ Coinsurance________ Deductible____________Personal Property of Others $____________________Personal Property of Others is Personal Property in your Care, Custody and Control. (i.e. Guns left for repair or storage). This coverage is not automatically included in “Business Personal Property” Personal Property of others in “club member” lockers: # of Lockers _______Section 5RANGE OPERATIONS____Please Quote ____None At This TimeNumber of Lanes at your Range: INDOOR______ OUTDOOR_______ Type of Range (check all that apply) Pistol ____ Rifle ___ Archery_____Does Applicant have an outdoor Field Range? YES NO If yes, Dimensions Range: ____________________ Maximum Distance Shot: __________________What is the maximum distance of your other range lanes? ____________________If multiple lanes, show number of lanes here ________with distance here ________What kind of backstop or berm is used in your operations? Please describe in detail (photos help): _____________________________________________________________________________What kind of ventilation system does your range use? Please describe in detail: ______________________________________________________________________________What is the Distance to nearest EMS/First Responder facility? __________ (Miles)Does the range have a public address system that all shooters can hear? YES NO How Does Applicant determine the shooter’s level of experience with bow/firearm?__________________________________________________________________________________Does Applicant require NRA certified Range Safety Officer(s) in each range which has shooters? YES NO If yes, please give the number of Range Safety Officers you deploy: _______Is the range in compliance with any recognized standards? YES NO If so, please list (AAC, NFAA, etc.): __________________________________________________What is the minimum age of an unaccompanied shooter in the range? ____What is the minimum age of a shooter accompanied by an adult/ guardian? ____Does Applicant require parent/legal guardian be present with underage shooters? YES NO How is the premises secured and locked when not in operation? Please explain_____________________________________________________________________________________________________Is the range visible from the retail section? N/A YES NOIs there a viewing /waiting area located on premises? YES NO Are range rules and safety guidelines posted in a conspicuous manner? YES NO (Please provide copy or clear image of guidelines)If yes, please provide number of postings ___________ and type (video/static) __________Are rules and guidelines verbally reviewed with the shooter? YES NO Are shooters required to sign liability waivers? (Attach a copy) YES NO Does Applicant require reviewing of range safety video and initialing of waiver? YES NO Are the shooter owned firearms/ammo inspected at each check in? YES NO If yes, by whom: ______________________________________Are Fully Automatic Firearms allowed to be used at Range? YES NO Is ammo allowed that is steel “brass”? YES NO Tracer or incendiary? YES NO Armor piercing? YES NO Are eye and ear protection mandatory YES NO Does the range offer eye/ear protection for rent/rent? YES NO Are first aid kits located at each range? YES NO Please advise the number of employees with First Aid Certification or Medic training __________Does Applicant provide Lessons? YES NO Please describe (self-defense, marksman, safety, etc.) ________________________________________________________________________How many instructors as employees? ______ FT _______PTHow many instructors are independent contractors? FT ______ PT _____If “independent”, does Applicant require them to hold Professional Liability Insurance? YES NO Is the entity an Additional Insured on Instructor’s policy? YES NO Does Applicant rent to customers any of the following: handguns_____ semi-automatic firearms_____Fully automatic firearms_____ rifles _____ bows______ suppressors______Please advise what form of identification is required from the renter? (i.e. driver’s license, photo ID’s)_____________________________________________________________________________________What are the age limits for rental customers? ___________How Does Applicant determine the experience of the renter prior to providing the rental? Please explainDoes Applicant provide or sponsor any league or competitive shooting? YES NO If yes, please describe: _______________________________________________________If yes, what is the frequency: __________________________________________________Are fire extinguishers located at each Lane Section? YES NO Does Applicant sell, rent, or directly provide any of the following: beverage alcohol_____ prepared foods_____ catering services_____ clubhouse or space for private functions______Describe controls and protocols used to prevent participation of consumers of alcohol?______________________________________________________________________________Liquor License Number, State, and Expiration: _________________________________________Please provide the average number of firearms in your inventory as well as values detail below for Business Personal Property OR entered in “Retail” Section: Business Personal Property Consists of:Long guns $# NEW IS: # USED IS:Hand guns$# NEW IS: # USED IS:Gun parts$Ammunition$Powder$Sporting goods$Property in Transit $From gun shows/vendorsProperty off-campus$Displays/at gun showsFurniture/fixtures$Stock/ Other Retail items$Range Machinery/Equipment$Other Machinery /Equipment$Total Limit of BBP: $______________ Coinsurance________% Deductible $___________Personal Property of Others (Personal Property of Others is Personal Property in your Care, Custody and Control. (i.e. Guns left for repair or storage). This coverage is not automatically included in “Business Personal Property”) $____________________Personal Property of others in “club member” lockers: # of Lockers _______SECTION 6Gunsmith Operations_______Please Quote _______None at this timeDoes APPLICANT hold FFL 6 or a license 7? YES NO If yes, must also complete the Manufacturing SectionDoes Applicant use the services of any gunsmiths who are not employees? YES NO *If yes, please attach a certificate of insurance for each gunsmith used*Complete the following for each employed gunsmith (including owners):NameYears’ ExperienceSpecial Training/ CertificationGunsmith Revenue PRIOR YEAR $ ________ CURRENT YEAR $ ______________ PROJECTED $ _________Describe gunsmith services offered: _______________________________________________________Does Applicant’s services include any ‘bluing’ or other hot surfaces? YES NO If yes, is your bluing facility outside of the main building? ____________________________________List the specific services that you perform by attaching a copy of your service price list, showing the specific services you provide.Does Applicant alter firearms from the original factory specifications? YES NO If yes, please describe alterations:_______________________________________________________Does Applicant build or assemble firearms? YES NO If yes, please complete the following:Does Applicant obtain Certificates of Insurance from your source providers, showing Products coverage? YES NO Number of units assembled per year_________________________________________Number of actions/receivers supplied by the customer____________________________Number of actions/receivers supplied by you______________________________________Does Applicant pay any Federal Excise Tax? YES NO Does Applicant’s name appear anywhere on the firearm? YES NO If yes, please describe:__________________________________________________________________Are the actions/receivers thoroughly checked prior to assembly? YES NO Does Applicant always test the firearms after assembly and document? YES NO Does Applicant provide an owner’s manual with handling, or safety instructions? YES NO *include a sample of the manual, and/or instructions*ADDITIONAL INFORMATION ON GUNSMITH ACTIVITIES:INCLUDE SPECIAL TOOLS, AND INFO ON SERVICES.Section 7 Automatic (NFA) Firearms Supplemental Questions______Please Quote ______None At This Time(Use for Sale or Rental Operation)Number of fully automatic firearms sold: ______________________Number of fully automatic firearms on premises: ______For sale ______ For rent _______If rentals, what is the age requirement to rent fully automatic weapons? ____________What is the minimum age you/your entity allows in operating (firing) NFAs? ____________Who is the customer base to whom you sell/market your fully automatic firearms? ___________________________________________________________Where and how are the fully automatic firearms stored during business hours? ___________________________________________________________________________________________After business hours? _____________________________________________________________Estimated revenue from sales of fully automatic firearms? _______________________________Estimated revenue of rental of fully automatic firearms? ________________________________ADDITIONAL INFORMATION FOR THIS SECTION:SECTION 8 BLACK/SMOKELESS POWDER______Please Quote ______None At This TimeDoes Applicant sell or distribute black powder? YES NO If yes, what amount, estimated in pounds, of black powder is in display? _________ lbsDescribe how storage/handling is in compliance with applicable Federal, state, and local regulations? Please explain: _______________________________________________________________________Describe how you store your stock of black powder that is not displaced (Including types of magazines and/or containers): Note: Safes are not acceptable____________________________________________________________________________________How much smokeless powder does Applicant display? ____________________ lbsHow Does Applicant store the remainder of the smokeless powder not on display? ____________________________________________________________________________________Has your local fire department approved your storage of Black and/or smokeless powder? YES NO (Attach written approval or certificate)REMARKS SECTION FOR EXPANSION OF ANSWERS:SECTION 9 HUNTING LODGES/ PRESERVES & SHOOTING CLUBS______Please Quote ______None At This TimeOPERATIONS INFORMATIONRevenue from operations: ____________CURRENT YEAR $ __________________ PRIOR YEAR $ ______________ PROJECTED $ _________For Profit Club _____ or Not For Profit _____ Private (membership only) ______Number of Acres # ____ in County ___________State_______ If leased, # of Landowners ________Vacant Property? If so # of Acres ________Number of bodies of water greater than 3 acres? _____________Any “feed plots” crop areas, or other viticulture/horticulture? _______# of acresDoes Applicant require all guests to sign liability waiver? YES NO (ATTACH COPY) Does Applicant hire guides as sub-contractors? YES NO If yes, for what activities? ________________________________________________________________Does Applicant’s hired guides/outfitters provide Evidence of Insurance, in favor of Applicant? YES NO Describe safety procedures and/or attach safety guidelines: ____________________________________PREMISES INFORMATIONAre there buildings at your facility with limited access due to forest, terrain or season? YES NO Is your business operational year around? YES NO If no, provide the months you are operational?JANFEBMARAPRMAYJUNJULYAUGSEPTOCTNOVDECIf no, is there a caretaker on site? YES NO Contracted? YES NO If no, are buildings winterized? YES NO Does any building have wood burning fireplaces and/or wood stoves? YES NO Total number of units for guest rental:_____________________________Number of RV spaces__________ Maximum number of tent sites: ______Maximum guest capacity is: _______Describe level of services offered (i.e. water/sewer hookups, electrical, grills, etc.)_______________________________________________________________ Does applicant have a dumping station or on-site waste treatment? YES NO Are daily “rounds” checks of the campground conducted? YES NO Does applicant hire security services? YES NO Does applicant use employees for security services? YES NO Does Applicant engage in any forest management practices? If yes, explain: ___________________________________________________________________________________________________________SWIMMING AREASHow many of each: Pools ______ Lakes _______ Other: _____If you have pools, are the rules posted? YES NO Are all pools and spas complaint with local and State safety guidelines? YES NO Are all pools and spas compliant with Virginia Graeme Baker Pool and Spa Safety Act? YES NO Are the swimming pools fenced? YES NO If so, what is the type & height of the fence? _______________ (Please provide photos of the fence)Do you have a diving board? YES NO How does applicant manage access to swimming lake areas? ___________________________________Are there lifeguards employed for both the pools and lakes? YES NO If no, is there a sign stating “No lifeguard, swim at your risk”? YES NO (Please provide photos of the signage)Does the applicant sell, rent, or directly provide any of the following: Alcohol Beverage_____ Prepared Food_____ Grocery Items ____ Tobacco _____ Catering Services_____ Clubhouse or space for private functions______Liquor License Number, State, and Expiration: _________________________________________SECTION 10 GUIDES/OUTFITTERS______Please Quote ______ None At This TimeOperations InformationRevenue from Guide/ Outfitting operations: ___________________________CURRENT YEAR $ __________________ PRIOR YEAR $ ______________ PROJECTED $ _________Does Applicant require guests to sign a liability waiver?(ATTACH COPY) YES NO Does Applicant hire guides as sub-contractors? YES NO If yes, for what activities? ___________________________________________________________Does Applicant’s hired guides/outfitters provide Evidence of Insurance, in favor insured applicant? YES NO Check the months in which the outfitter/guide business operates: JANFEBMARAPRMAYJUNJULYAUGSEPTOCTNOVDECWhat is the maximum guide to guest ratio? Guides __________ Guests ____________What is the maximum number of participants at any one time? _____________________________Do guides carry any communication device with them (2-way radio, cell phone, etc.)? YES NO If yes, please explain what type _______________________________________________Does Applicant provide a written safety manual of procedures to all staff members? YES NO What percentage of the following enhancements does applicant provide?WITH GUIDES/SUPERVISIONWITHOUT GUIDES/SUPERVISIONENHANCEMENTTrails/hikesClimbing/rappelling/zip linesCanoes/kayaks/paddle boatsMotorized boats (electric or fuel)Cross country skiingTrappingFishingHunting animalsRetrieval animalsTrail ride animals (donkey, horse)ATVs (single riding)UTV’s (side by sides)SnowmobilesGame stock (birds, rabbits, etc.)What is the minimum age of participants in above activities? _______________ GUIDE INFORMATIONNameAgeYears’ ExperienceFirst Aid QualificationsEQUIPMENT/INLAND MARINEPlease select the aggregate (total) limit options to insure sporting equipment, kayak/rafts/ boats <25 feet: ____ none (self-insured) ______ $5,000______ $10,000 ______ $15,000 ______ $20,000 SECTION 11- MANUFACTURING OPERATIONS______Please Quote ______None At This TimeOPERATIONS INFORMATION Does total revenues from all sources exceed $250 million in one year? YES NO If no, what is applicant’s gross annual revenue from manufacturing? (all locations) $_________________What actions does applicant perform that requires a Manufacturers License? ____________________________________________________________________________Provide the Class 6 or 7 FFL License information: Number: ________ Date Issued: ________Describe the products you manufacture (under any label). Include images of your completed product and a product description of how your products are advised to be applied/installed. Please, give the URL AND Name, location of any associated Marketing websites: ___________________________________________________________________Loss Control/Product Recall or Claims HandlingDoes Applicant have written Safety Program & designated person who implements/manages the program? YES NO Has your written product recall procedures been reviewed by legal counsel? YES NO *If yes, please include an image of the Procedures*Does Applicant have a written procedure for accidents, injuries, complaints, involving your products? YES NO If yes, does Applicant provide for examining, preserving and storing of any allegedly defective product? YES NO How many years are the results recorded and maintained? _______ Does Applicant maintain consent forms from your distributors that enable you to obtain investigative product information when required? YES NO Does Applicant make consumers aware of its need to obtain investigative information when required? YES NO Does Not Apply Since the inception of your company, have you issued or been notified of any defect in any of your products? YES NO Are you aware of any defects in any products you sell or have formally agreed to sell in the future? YES NO If yes, please explain: _______________________________________________________Since the inception of your company, have you issued any “products recall” or been notified by any related party of any products recalled? YES NO If yes, please explain: ___________________________________________________________Does Applicant offer training and/or instructions in the designed use of your products? YES NO If yes, please explain: _________________________________________________________Ammunition Products Manufacturing Revenue CURRENT YEAR $ __________ PRIOR YEAR $ ______________ PROJECTED $ __________Does Applicant assemble or manufacture ammunition to the specifications of customers? YES NO If yes, does Applicant require product be tested upon receipt? YES NO Do you import foreign products that go into the products you manufacture? YES NO If yes, what products: ____________________________________________Does Applicant distribute foreign products that Applicant imports directly? YES NO If yes, from what country? _____________________________________________If yes, are you an Additional Insured onto their foreign policy? YES NO (Please provide copy of AI & Certificate of Insurance)Have you discontinued or are considering discontinuing any product(s) to be covered by this insurance policy? YES NO If yes, please describe: _______________________________________Are you contemplating any new products? YES NO If yes, please describe: _______________________________________________________________RELOADING OPERATIONS:Revenue CURRENT YEAR $ _____________PRIOR YEAR $ ______________ PROJECTED $ _______Does Applicant manufacture or reload ammunition? Manufacturer ______ Reload ______ Both____ Please provide any formal training (e.g. NRA course completion and certified):____________________________________________________________________________________(Please attach copy of any certifications)Does Applicant utilize a reloading reference manual? YES NO If yes, please provide the Name and Edition Date: _____________________________________Do you identify yourself on the product packaging? YES NO If yes, please provide copy of packing with instructions and warning labels.Does Applicant put a serial number or a print identifier on your packaging that identifies your product? YES NO Are the casing(s) utilized in your process? New_____ Used _____ Both _______Are casing(s) brass, steel, nickel or other? (i.e. aluminum): _______________________________Are quality control measures in place to check individual product runs? YES NO If yes, please advise how results are recorded and kept for reference: _____________________________________________________________________________________Does Applicant randomly test products/ammunition? YES NO Does Applicant provide a written owner’s manual, warning and safe handling instructions? YES NO If operations are reloading ammunition, please identify the equipment utilized? Shell Holders_____ Measuring tools_____ Metal Resizing equipment_____ Loading blocks______ Case Preparation_____ Reloading press____ Reloading dies_____Powder handling equipment_____ priming tools_____ case cleaning_____ Bullet casting_____Is process automated? _____ Is process manual?_____Please describe how you check for gas, lube & sizer dies, top punches, cast molds, etc.? _____________________________________________________________________________Does Applicant store primers? YES NO If yes, average quantity? _____________If yes, how does Applicant store the remainder black/smokeless powder and primers? ____________________________________________________________________________If yes, does Applicant comply with NFPA 495 storage procedures? YES NO Does Applicant have written verification of compliance from the Local Fire Department? YES NO *If yes, please provide a copy.Is a casting furnace utilized in your operations? YES NO If yes, please advise the placement of the furnace____________________________________If yes, please advise how the area is ventilated_______________________________________If yes, is it in primary building or in a building/separation of 30 feet from primary building? ____________________________________________________________Is Applicant’s production building equipped with a fire sprinkler system? YES NO What % of building is sprinkler protected? __________________ %With whom is Applicant contracted with for the maintenance of the sprinkler system? _________________________What are the applicant’s procedures in the event of a fire? ____________________________________Does Applicant have firewalls within your building(s)? YES NO If yes, please describe how Applicant separates flammable materials within the operations: _____________________________________________________________________________________FIREARMS RELATED [OTHER THAN AMMUNITION] MANUFACTURING:Revenue CURRENT YEAR $ ____________ PRIOR YEAR $ ______________ PROJECTED $ ____________Does Applicant/employees or Applicant’s entity perform the design work of products? YES NO If yes, Please describe: ____________________________________________________________If No: identify the designer: ______________________________________________Does Applicant maintain Evidence of Insurance from the designer(s)? Yes: ____ No: ____Are Applicant’s products reviewed by ______ independent review, _______tested by Universal Laboratories ______ or ______ by in-house design engineers? How Does Applicant verify its’ written quality control and testing procedures are followed? __________________________________________________________________________How many years does Applicant maintain quality control records? __________Do Applicant records indicate the data and procedures followed when each product was tested? YES NO Does Applicant subcontract (out) any of your manufacturing or gunsmith operations? YES NO If yes, does Applicant (1) have written agreements in place YES NO, (2) verify it’s sub -contractors insurance YES NO, (3) are named as an Additional Insured? Must respond for all three. If no, please explain your arrangement:___________________________________________________________________________________________________________________________________Does Applicant build or assemble firearms? YES NO If yes, number of assembled per year: ______If yes, describe the firearms assembled/built: # pistols: ___________ maximum caliber: ________# rifles: ____________ maximum caliber: _______ Bolt Action/SingleRepeater/MagazineSemi -AutomaticAutomaticYES NOYES NOYES NOYES NODoes Applicant manufacture the receiver? YES NO Please include your Quality Control procedures, Testing Procedures. _____________________________ If no, from whom does applicant purchase receivers? __________________________________Are the actions/receivers thoroughly checked prior to assembly? YES NO Are they new or refurbished?New_____ Ref_____Does Applicant alter firearms from the original factory specifications? YES NO Does Applicant test fire the firearms/ products after assembly? YES NO Does Applicant put a serial number on the firearms/products you manufacture? YES NO Please advise location and type of imprint: ____________________________________________SECTION 12: EMPLOYEE BENEFITS LIABILITY OPTIONAL COVERAGE______Please Quote ______None At This TimeEMPLOYEE BENEFITS Limits of Liability requested: (select one each column)Limit OccurrenceAggregate Limit25,00050,00050,000100,000100,000100,000Retroactive Date: ___/____/_______. If the retroactive date is prior to the policy effective date, please provide evidence of prior coverage showing the retroactive date. Number of Employees considered via current Employee Benefits Program _________ If Applicant does not have a program, will Applicant be starting one in the proposed Policy Term? YES NO Number of employees not in the United States? _____ What Countries? __________________Number of employees covered/ to be covered by the Employee Benefits Plan: _____Employee Benefit Programs to be offered (O) are (check all applicable): If any of the below are “involuntary” (automatically included) please check the “I” box as well OIOIGROUP LIFE INSURANCEDISABILITYGROUP DENTALGROUP HEALTHGROUP ACCIDENTUNEMPLOYMENTSOCIAL SECURITY BENEFITSWORKER’S COMPENSATIONANCILLARY BENEFITSPROFIT SHARING/STOCK PLANSOPTICAL/VISIONVACATION PROGRAMSOTHER? OTHER? Is all correspondence regarding Applicant’s Employee Benefit Program made in written form? YES NO On programs permitting employees an option to enroll or not to enroll, does the applicant require a signed acceptance or rejection from each employee? YES NO If no, explain __________________________________________________________________________ __________________________________________________________________________ Are benefit plans jointly administered (i.e., trustees elected or appointed by management and union)? YES NO Are benefit plans administered by an outside third-party administrator? YES NO If “Yes”, name of Administrator _______________________________________Do they carry errors and omissions liability insurance of at least $1,000,000? YES NO If no, number of employees in charge of administering the Employee Benefits Plan: __________What are the qualifications of employee benefits counselors and benefits administrators? ________________________________________________________________________________Are personnel who are counseling employees trained using information and tools from the Providers? YES NO Has any error or omission loss ever been sustained? YES NO If yes, give details:_________________________________________________________________Are stock subscriptions or profit-sharing plans equally available to all full-time employees? YES NO Does your company form part of a franchise? YES NO Is the Employee Benefits Program offered to insured’s non-employees? YES NO Does Applicant administer any Benefit Plans for others? YES NO If yes, please explain: ______________________________________________________________Are all Programs in compliance with COBRA requirements? YES NO If no, please explain:_______________________________________________________________If multiple locations exist, is administration centralized? YES NO If no, please explain:_______________________________________________________________How are employees in branches and other locations advised of benefits? Describe:________________________________________________________________________ Who was your prior Employee Benefits carrier? ___________ Expiration: ____________Has coverage ever been declined or cancelled? YES NO If yes, please explain:_______________________________________________________________ Has applicant rejected the Workers Compensation Act(s) in any State (NJ and TX applicants must answer)? _____________________________________________________________________________Are you aware of any claims that have been in the last five years, or impending now that may be brought against you regarding the Employee Benefits Program? YES NO If yes, please explain:________________________________________________________________________________________________________________________________________________________As the authorized person to respond for the applicant, does the applicant or any Officer or Director have knowledge of or information of any occurrence which might give rise to a claim, either presently or in the preceding (5) five years? YES NOIf yes, please explain: ______________________________________________________________________________________________________________________________________________________ If this insurance had been in force during the past five years, would any claim have been presented?If yes, please explain:__________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________SECTION 13 EMPLOYMENT RELATED PRACTICES LIABILITY COVERAGE _____Please quote ______None At This TimeLIMITS REQUESTED:LIMITRETENTION100,0005000250,00010000500,00025,000NOTE: With respect to the information required to be disclosed in response to the questions IN THIS SECTION, the proposed insurance will not afford coverage for any claim arising from any fact, circumstance, situation, event or act about which any executive officer of the Applicant had knowledge prior to the issuance of the proposed policy, nor for any person or entity who knew of such fact, circumstance, situation, event or act prior to the issuance of the proposed ANIZATION INFORMATIONIs requested coverage to include entities other than those named in this policy which are more than 50% owned, or joint ventures that are at least 50% owned by the Applicant, either directly or indirectly?In the next 12 months (or during the past 24 months) is the Applicant contemplating (or has the Applicant completed or been in the process of completing) the following:Any actual or proposed merger, acquisition, or divestiture?Any branch, location, facility, office, or subsidiary closing, consolidations or layoffs?If either of the above are answered yes, please attach an explanation, including the timing, the essential terms of the event, arrangement, impact on employee base, and the surrounding circumstances.EMPLOYEE INFORMATIONWhat percentage of the Applicant’s employee base is outside the U.S.? ________ %Exempt ____% Non-Exempt ____%Please complete the following to state the number of Full Time (32 HOURS OR BENEFITS ELIGIBLE) and Part Time employees, Volunteers, and natural person Independent Contractors:CURRENTLY# FULL TIME# PART TIME # VOLUNTEERS# IND CONTREMPLOYEESVOLUNTEERSINDEPENDENT CONTRACTORSPRIOR 12 MONTHS# FULL TIME# PART TIME # VOLUNTEERS# IND CONTREMPLOYEESVOLUNTEERSINDEPENDENT CONTRACTORSFurther, then please show the maximum number of employees at any one date during the previous 12 months for:LEASEDTEMPORARYSEASONALUNION Number of employees:Compensated less than $50,000 annually: _______Compensated more than $100,000 annually: ______Within the past 24 months has an audit been conducted:Regarding the payment of wages, including equal pay and overtime pay? YES NO If yes, by whom/role? ________________________________________Regarding the classification of individuals as exempt v. non-exempt employees or as independent contractors? If yes, please explain: ______________________________________________________________________________________________________________ Provide the percentage of employee turnover figures for each of the last 3 years for:Terminations ofCurrent year1st prior ______2nd prior ______VoluntaryLayoff/DownsizingOther than aboveWithin the past 24 months how many officers have been involuntarily terminated or laid off? ________Prior to employee terminations does the Applicant consult with the following:Human Resources personnel? YES NO An attorney with experience in employment law? YES NO Does the Applicant provide severance packages to terminated or laid off employees? YES NO If yes, does the severance agreement include a Waiver or Release of an employee’s rights to bring a claim against the Applicant? YES NO Does the Applicant have a Human Resources department? YES NO If yes, # of staff is ______.Are all prospective employees required to complete a uniform employment application prior to hire? YES NO Does the Applicant have an employee handbook that is distributed to all employees? YES NO Are employees required to acknowledge, by signature, receipt of employee materials? YES NO Does the employment application or employee handbook contain an “Employment at Will” statement? YES NO Complete the following for guidelines, policies and procedures related to:FORMALLY WRITTEN EMPLOYEE VERIFIES RECEIPTDISCRIMINATIONHARASSMENT, SEXUAL OR OTHEREQUAL OPPORTUNITY EMPLOYERFMLA (Family Medical Leave Act)DISABLED Employee AccommodationsRETALIATIONEmployee COMPLAINT ResolutionEMPLOYEE DISCIPLINEPERFORMANCE APPRAISALSALARY ADMINSTRATIONHIRING ONBOARDINGDISCHARGE/TERMINATIONDoes the Applicant: YESNOHave written policies or procedures outlining employee conduct when dealing with the general public, customers, clients, vendors, or other third parties?Have written policies or procedure for dealing with complaints from the general public, customers, clients, vendors or other third parties of issues involving harassment or discrimination?Conduct human resources training on guidelines, policies and procedures for all individuals who handle human resources functions?Conduct training for employees on issues of discrimination, sexual and other workplace harassment?Have the above and the employment practices policies, procedures and employee handbook periodically review by legal counsel?If the Applicant is a federal contractor subject OFCCP, has the Applicant been subject to compliance evaluation or investigation in the past 3 years? YES NO If yes, please explain: _________________________________________________________________WARRANTIES RELATED TO EMPLOYMENT PRACTICES LIABILITY SECTIONHave any employment-related claims or administrative, criminal or regulatory proceedings, charges, hearings, demands or lawsuits been made against the Applicant or any person proposed for this insurance during the past 3 years, whether or not insured, including claims involving employees or independent contractors?If yes, please explain: _________________________________________________________Has any claim, demand or lawsuit been made against the Applicant or any person proposed for this insurance involving sexual harassment or discrimination brought by the general public, customers, clients, vendors or other third party?If yes, please explain: __________________________________________________________SECTION 14 CYBER LIABILITY OPTION______Please Quote ______ None At This TimeDoes the Applicant have any currently in force Cyber Liability coverage? YES NO If yes, please give: Carrier, Retroactive Date, Limits, and expiry: CARRIERLIMITSEXPIRYRETROACTIVE DATEAre there any currently provided cyber related coverages—even as part of a package or vendor provided-- that would duplicate or interfere with the OSR cyber liability addressing: COVERAGEYESNODate of EventData Breach/Incident ResponseNetwork Security, Privacy, Data Breach LiabilityPCI Fines and AssessmentsBusiness InterruptionData RestorationCyber ExtortionHas the Applicant ever directly experienced a loss or incident related to the above 6 coverages? YES NO If yes, please describe: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Does the applicant use ONLY financial services that present evidence that they are PCI compliant? YES NO Is applicant’s data backed up at least once per week, AND stored separately from host location? YES NO Are anti-virus software and firewalls updated at least quarterly? YES NO Is there a patch management policy to implement critical patches/updates within 30 days of release? YES NO Within the last Five (5) years, have any ‘principal operatives’ of the applicant received, or have any awareness of, any circumstance, situation, event, transaction, pending claim, complaint or similar cyber/data infringement which may give rise to a claim related to the 6 coverage features in this Section? YES NO What is the percentage of applicant’s business that is e-commerce? _______%For e-commerce, does applicant use a third party enterprise system that is PCI compliant? YES NO Does applicant anticipate any new e commerce products or services in the coming 12 months? YES NO Does applicant’s website(s) use metatag technology? YES NO Does applicant’s computer use policy address portable device and data use security? YES NO Does applicant engage legal counsel to review the web, cyber, e-commerce activities? YES NO Select the one Coverage option requested: LIMITYES250,000$ 500,000$1,000,000The deductible offered will be determined by underwriting criteria.Section 15-EVERY APPLICATION REQUIRED ITEMSApplicable documents are required for final quotes or binding submission. Not providing the following may result in delay of offering terms.All brochures describing any and all products and services Your Liability Waiver documents for members, patrons, guests. Product safety manuals, warnings, literature regarding use and/or maintenanceCopy of current federal firearm licensesAny and all liability Waiver/Hold Harmless Agreement(S) you may require, if applicableDetails of any ATF ViolationsNew Ventures – Provide resume of experience; certification; specialized trainingCurrently valued insurance company loss runs for the current policy period plus 3 years or a No Known Loss Letter signed and dated by the insured on new venturesGunsmith Services ListingBuilding Valuation toolsEmployee handbook, Other links/ images/info of documentation to support APPLICANT’S business as a best in class facilityCOMPLETED ACORDS including associated: 125 Application 126 Liability 131 Umbrella 130 Workers Compensation Section 16-ADDITIONAL INFORMATION FROM ANY PREVIOUS SECTIONSNote: This application is to provide information only for the purposes of underwriting considerations. Any coverage terms offered will be subject to the terms, conditions and exclusions of the policies as issued. This application is not an offer of insurance, and provides no insurance coverage. Signers Affirmation: I/We understand that any person who knowingly and with intent to defraud any insurance company, agent, broker, or another person; who 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 that subjects the person to prosecution of criminal and civil penalties. Applicant’s Signature ________________________________________ Dated ____________________Applicant’s Name (please print) _______________________________ Title ______________________The undersigned is an authorized representative of the applicant and represents that reasonable Inquiry has been made to obtain the answers to the information inquiries of this application and supporting documents/exhibits. By signing, you represent and warrant that the answers are true, correct, and complete to the best of your knowledge. Signature herein and on any Acord Forms acknowledges review of and awareness of the applicant’s respective State’s particular notices of fraud prevention Statements. Producers’ Signature________________________________________ Dated ______________________Producer’s Name (Please print) _______________________________PRODUCER’S AGENCY/ENTITY _________________________________________________OUTDOOR SPORTS AND RECREATION PROGRAM STATEMENT OF INFORMATION TECHNOLOGY SYSTEMS SECURITYI/We represent _____________________________ that the following are accurate: The Applicant performs back-up of data at least once per week and store these back-ups in a location that is separate from our physical premises;The Applicant has anti-virus software and firewalls in place which are updated on at least a quarterly basis;The Applicant affirms that the Applicant’s vendors have presented evidence of PCI compliance; The Applicant practices a patch management policy in place that implements critical patches within 30 days of their known release;In the last 5 years, The Applicant (including any directors, officers or C Suite members) has not received, nor are there currently pending, any claims, complaints or incidents which may be covered under the proposed insurance;The Applicant (including any directors, officers or C Suite members) does not have knowledge of any fact, circumstance, situation, event, or transaction which may give rise to a claim or loss under the proposed insurance. I confirm that the revenue for the annual period ending __________ was $ _______________(USD).I/We affirm that the above representations give a fair presentation of the risk.The Applicant or Applicant’s Agent will immediately notify the Underwriters, before any policy is concluded, of any new or newly-discovered information that would have been included in the representation if known at the time of submission of this document.The Applicant understand that if there is a failure to comply with the above, then the Underwriters will have the right to deny and claims addressed by this cover, to cancel or non-renew the policy, or to make rate adjustments, at the discretion of the Underwriters. The above representation clauses shall prevail to the extent that they are permitted, or may otherwise be amended, by any similar provisions of any foreign, federal, state, or local statutory or common law and any rules or regulations promulgated under such laws.Signature________________________________________ Dated _____________________ ................
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