OUTDOOR SPORTS AND RECREATION INSURANCE



AGENCY INFORMATIONAgency Name: FORMTEXT ????? Contact Name: FORMTEXT ????? Phone: FORMTEXT ?????Email: FORMTEXT ?????Submission Required Items:Website / Brochures describing any and all products and services Liability Waiver documents for members, patrons, guests. Applicable for indoor/outdoor rangesRange Rules Copy of current Federal Firearm LicensesDetails of any ATF ViolationsNew Ventures – Provide resume or experience documentation / Business PlanCurrently valued loss runs for 4 years Gunsmith Services ListingBuilding Valuation toolsEmployee handbook – needed with EPLI*Every submission must include the Acord 125 & 126** Acord 131 are on an as needed basis*INSURED INFORMATION Named Insured: FORMTEXT ?????DBA: FORMTEXT ?????Primary contact person: FORMTEXT ????? Phone: ( FORMTEXT ?????) FORMTEXT ?????Email FORMTEXT ????? Website: FORMTEXT ?????Mailing Address: FORMTEXT ?????City: FORMTEXT ????? County FORMTEXT ????? State: FORMTEXT ????? Zip: FORMTEXT ?????Federal Employee ID: FORMTEXT ?????or Social Security #: FORMTEXT ?????Entity Form: Corporation FORMCHECKBOX Partnership FORMCHECKBOX Individual FORMCHECKBOX LLC FORMCHECKBOX Other: FORMCHECKBOX Number of years in business: FORMTEXT ????? If new venture, how many years of experience? FORMTEXT ?????Location Address: FORMTEXT ?????City: FORMTEXT ????? County: FORMTEXT ????? State: FORMTEXT ????? Zip: FORMTEXT ?????IF MULTIPLE LOCATIONS, CHECK HERE FORMCHECKBOX COMPLETE Section 2 or provide an ACORD 140Please describe your business: FORMTEXT ?????Indicate the organizations you are a member of: FORMCHECKBOX NSSF FORMCHECKBOX NAFR FORMCHECKBOX NRA FORMCHECKBOX NASR FORMCHECKBOX Other FORMTEXT ?????Proposed effective date of coverage: FORMTEXT ?????CLASSIFY THE APPLICANT OPERATIONS: Check all that applyOperation Key Component ISO GL Rifle/Pistol Shooting Range Indoor 47253 FORMCHECKBOX Outdoor47254 FORMCHECKBOX Archery Ranges Indoor 10052 FORMCHECKBOX Outdoor 10054 FORMCHECKBOX Retail Gun & AccessoriesSporting goods stores18206 FORMCHECKBOX Apparel / Accessories 11127 FORMCHECKBOX Instruction Classroom 47253 FORMCHECKBOX RentalSporting Goods (Not Range) 18206 FORMCHECKBOX Gunsmith 95620 FORMCHECKBOX Hunting Hunting Clubs45224 FORMCHECKBOX Hunting Preserves45225 FORMCHECKBOX LodgingB&B, Lodges45192 FORMCHECKBOX Guides Guides/Outfitters44222 FORMCHECKBOX Manufacturing Limited accessories and small-arms ammo only51211 FORMCHECKBOX Food ServicesRestaurant / Café FORMCHECKBOX Liquor Liability Serve at Location FORMCHECKBOX Take Out FORMCHECKBOX GENERAL OPERATIONSIs club/ organization membership required? FORMCHECKBOX YES FORMCHECKBOX NO If yes, please provide copy of membership agreements.List all Federal Firearm Licenses applicant holds and included copies of each:Class FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? (IF YOU HAVE A CLASS 6 or 7 FFL, You are required to complete the Manufacturing Supplemental)Does Applicant operate any other business (s) from ANY location? FORMCHECKBOX YES FORMCHECKBOX NO If yes, please List Name and Description of other business(s): FORMTEXT ?????Does Applicant have separate insurance for the other business(s)? FORMCHECKBOX Yes FORMCHECKBOX NO Does Applicant sell products to any entity that requires Applicant to name them as an Additional Insured? FORMCHECKBOX YES FORMCHECKBOX NO Does Applicant have any contracts or lease agreements that require Applicant to name another party as an Additional Insured? FORMCHECKBOX YES FORMCHECKBOX NO ADDITIONAL INSURED INFORMATION NAMECOMPLETE ADDRESSINTEREST/REASON FOR A.I. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Does Applicant offer any warranties on any products Applicant’s company makes or modifies? FORMCHECKBOX YES FORMCHECKBOX NO Does Applicant sell any products that extend beyond the manufacturer’s warranty period? FORMCHECKBOX YES FORMCHECKBOX NO Does Applicant sell any products that have an enhanced or expanded warranty? FORMCHECKBOX YES FORMCHECKBOX NO Does Applicant have pawn operations? FORMCHECKBOX YES FORMCHECKBOX NO What are the applicant’s hours of operation (AM to PM)SUNDAYMONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAYSATURDAYRANGE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????RETAIL FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????OTHER FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????REGULATORY INFORMATION:Is Applicant requesting “Regulatory Entity Defense Coverage” (ATF Hearing)? FORMCHECKBOX YES FORMCHECKBOX NO What was the date of Applicant’s last ATF inspection? FORMTEXT ?????Were there any ATF violations cited? FORMCHECKBOX YES FORMCHECKBOX NO If yes, please describe the citation(s) and the resolution: FORMTEXT ?????Has Applicant ever experienced any corrective action from an Environmental/EPA or Occupational/OSHA entity? FORMCHECKBOX YES FORMCHECKBOX NO If yes, please describe the citation(s) and the resolution, including dates: Name: FORMTEXT ?????Phone#: FORMTEXT ?????Email: FORMTEXT ?????Please list name and contact of the person responsible for compliance management: FORMTEXT ?????Are all activities and locations to be covered in full compliance with applicable federal, state, and local regulations? FORMCHECKBOX YES FORMCHECKBOX NO PRIVACY AND SAFETY OF PERSONAL /PRIVATE INFORMATIONDoes Applicant use an integrated Point of Sale system? FORMCHECKBOX YES FORMCHECKBOX NO If yes, please name vendor & system used: FORMTEXT ?????Does Point of Sale or data storage system use encryption technology? FORMCHECKBOX YES FORMCHECKBOX NO Who (roles, not names) has access to customers’ private/personal information FORMTEXT ?????Applicant steps to protect customer personal data include: FORMTEXT ?????EMPLOYEE/STAFF INFORMATION:Number of Employees: FULL TIME: FORMTEXT ????? PART TIME: FORMTEXT ?????(FT= 32 hours/more per week)PAYROLL: Past 12 months: $ FORMTEXT ????? Projected Payroll next 12 months: $ FORMTEXT ?????Does Applicant hire/use contract workers for any operations, including instructors? FORMCHECKBOX YES FORMCHECKBOX NO If yes, what is the total number of contract workers used? FORMTEXT ?????What is the total annual premium paid to contract workers? FORMTEXT ?????Does Applicant involve volunteers in any business operations? FORMCHECKBOX YES FORMCHECKBOX NO Does Applicant conduct background checks/investigations on all new employees? FORMCHECKBOX YES FORMCHECKBOX NO Describe the method and steps used, to conduct employee checks: FORMTEXT ?????Does Applicant conduct benchmark testing for: FORMTEXT ?????Hearing FORMCHECKBOX YES FORMCHECKBOX NO Blood (lead, toxins, substances) FORMCHECKBOX YES FORMCHECKBOX NO Are there written safety and return to work policies, procedures, and rules for staff/employees? FORMCHECKBOX YES FORMCHECKBOX NO Does Applicant maintain “drug free workplace” standards? FORMCHECKBOX YES FORMCHECKBOX NO Does Applicant provide state sanctioned drug free workplace programs to all employees? FORMCHECKBOX YES FORMCHECKBOX NO If yes, how often? FORMTEXT ?????Are your employees versed in Federal, State, and Local Laws regarding the distribution of guns, ammunition and/or gunpowder (black or smokeless)? FORMCHECKBOX YES FORMCHECKBOX NO Does Applicant or employees hold any special certifications or training? FORMCHECKBOX YES FORMCHECKBOX NO If yes, please describe: FORMTEXT ?????Number of employees who may at any time use their personal autos in applicant’s operations. FORMTEXT ?????Does Hired/Non-Owned auto use ever include transporting hazardous materials or firearms? FORMCHECKBOX YES FORMCHECKBOX NO Does applicant obtain driver history (MVR) and evidence of employees’ insurance (for applicable employees)? FORMCHECKBOX YES FORMCHECKBOX NO Have all Officers, contract persons, and employees acknowledged they understand Form 4473 and have they been trained regarding Straw Sales, and all other federal and local laws concerning the sale of firearms, ammunition, black and smokeless powder? FORMCHECKBOX YES FORMCHECKBOX NO BUILDING INFORMATION. Please complete for each additional location or include ACORD 140 *If more than two locations please send an Excel SOV LOCATION # FORMTEXT ????? BUILDING # FORMTEXT ?????Physical Address: FORMTEXT ?????City FORMTEXT ?????County FORMTEXT ?????State FORMTEXT ????? Zip FORMTEXT ?????Construction Type: FORMCHECKBOX Frame metal/wood FORMCHECKBOX Joisted Masonry FORMCHECKBOX Tilt up concrete FORMCHECKBOX Masonry Non-Combustible FORMCHECKBOX Modified Fire Resistive FORMCHECKBOX Fire ResistiveYear built: FORMTEXT ????? Roof Surface (all that apply): FORMCHECKBOX TPO FORMCHECKBOX Built UP FORMCHECKBOX Metal Shingles Other: FORMTEXT ?????Date of last upgrades: Roof FORMTEXT ????? Electrical FORMTEXT ????? Plumbing FORMTEXT ????? HVAC FORMTEXT ?????OTHER FORMTEXT ?????If building is more than ten (10) years old describe maintenance of services: FORMTEXT ?????Number of floor(s): FORMTEXT ????? Square feet per floor FORMTEXT ????? Basement square footage: FORMTEXT ?????Total building area: FORMTEXT ????? Total area occupied FORMTEXT ????? square ft Is the building free standing FORMCHECKBOX YES FORMCHECKBOX NO Distance to nearest structure (in feet): FORMTEXT ?????Has this building been converted to present use from a different past use? FORMCHECKBOX YES FORMCHECKBOX NO Distance to nearest hydrant FORMTEXT ?????If none, please describe the water source in the area: FORMTEXT ?????Distance to & Name of nearest Fire Department: FORMTEXT ?????Paid FORMTEXT ????? Volunteer FORMTEXT ?????Within city limits FORMCHECKBOX YES FORMCHECKBOX NO Fire District FORMCHECKBOX YES FORMCHECKBOX NO ISO Protection Class 1 2 3 4 5 6 7 8 9 10 FORMTEXT ?????Does building have a sprinkler system FORMCHECKBOX YES FORMCHECKBOX NO If yes, what FORMTEXT ????? % or FORMTEXT ????? square feet Add sprinkler leakage coverage FORMCHECKBOX YES FORMCHECKBOX NO Date of last sprinkler test: FORMTEXT ????? Have all fire extinguishers /suppression systems been professionally inspected and tagged within the last year? FORMCHECKBOX YES FORMCHECKBOX NO Are fire extinguishers/sprinklers/suppression checked and signed each 30 days or less? FORMCHECKBOX YES FORMCHECKBOX NO Does the Applicant lease or own building(s): FORMTEXT ?????Number of Mortgages: FORMTEXT ?????Name and address of Mortgagee: FORMTEXT ?????Name and address of Loss Payee: FORMTEXT ?????If TENANT, does lease require Applicant to insure the Improvements & Betterments? FORMCHECKBOX YES FORMCHECKBOX NO If so, advise the “I & B” Replacement Cost? FORMTEXT ?????Does Leaseholder require they be named as Additional Insured? FORMCHECKBOX YES FORMCHECKBOX NO Are there any other tenants in the building? FORMCHECKBOX YES FORMCHECKBOX NO If yes, please describe FORMTEXT ?????IF other tenants/neighbors in the same structure, describe the fire separations that are in place FORMTEXT ?????Neighboring attached occupancies: Left FORMTEXT ????? Right FORMTEXT ????? Rear FORMTEXT ????? Front FORMTEXT ?????Amount of Building Coverage from your Insured Valuation Tool (include please):Building: $ FORMTEXT ????? RCV FORMCHECKBOX Deductible $ FORMTEXT ?????TOTAL value of Business Personal Property: FF&E, Inventory, Stock, etc. $ FORMTEXT ?????Signs: FORMTEXT ????? Please describe (monument/street/on building, etc.) FORMTEXT ?????If signs are not attached to the building, how far from the building are the signs located? FORMTEXT ?????Show details of the BPP in the respective Section(s) and enter total for this BUILDING HERE. FORMTEXT ?????LOSS OF BUSINESS INCOME/EXTRA EXPENSE $ FORMTEXT ?????(Use our worksheet or ISO CP 15 15)Coinsurance TIME ELEMENT: FORMTEXT ????? 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). FORMTEXT ?????EQUIPMENT BREAKDOWN COVERAGE Include FORMTEXT ????? Exclude FORMTEXT ?????a. Certification: SAAMI, ANSI, ISO? FORMCHECKBOX YES FORMCHECKBOX NO b. Maintenance contract FORMTEXT ????? With whom FORMTEXT ?????c. Deductible: 1000 FORMTEXT ?????2,500 FORMTEXT ?????5,000 FORMTEXT ?????10,000 FORMTEXT ?????d. Are any boilers or ‘pressure vessels’ in use at the facility (includes air compressors, pressurized tanks)? FORMCHECKBOX YES FORMCHECKBOX NO If yes, please explain: FORMTEXT ?????Are all equipment devices maintained in accordance with manufacturers recommendations: FORMCHECKBOX YES FORMCHECKBOX NO Location safety and security:Is there a watchman/security service on premises? FORMCHECKBOX YES FORMCHECKBOX NO Fire Alarm: FORMCHECKBOX YES FORMCHECKBOX NO Central FORMTEXT ????? Local FORMTEXT ?????Battery backup FORMTEXT ?????Intrusion Alarm: FORMCHECKBOX YES FORMCHECKBOX NO Central FORMCHECKBOX Local FORMCHECKBOX Battery backup FORMCHECKBOX Monitored by (entity) FORMTEXT ?????Smoke Detectors: FORMCHECKBOX YES FORMCHECKBOX NO Battery FORMTEXT ????? Hardwired FORMTEXT ????? Tied to Central? FORMTEXT ?????Describe your camera/visual monitoring systems:Doors are: FORMTEXT ????? Metal FORMTEXT ?????Glass FORMTEXT ?????FrameDo windows doors have metal bars or secondary protections (i.e; roll doors, bar grids)? FORMCHECKBOX YES FORMCHECKBOX NO If yes, please explain what is used: FORMTEXT ?????Describe gun safe storage manufacturer, type, class, (listed on the label on safe door)? FORMTEXT ?????Describe other protection: (Safe, dead bolt locks, metal bars, crash barriers in front of building, fire extinguishers, etc.) FORMTEXT ?????Does this location have other occupancies? FORMCHECKBOX YES FORMCHECKBOX NO If yes, please describe: FORMTEXT ?????Does Applicant have standby /emergency power generating equipment? FORMCHECKBOX YES FORMCHECKBOX NO If yes, is it 100% for emergency use only FORMCHECKBOX YES FORMCHECKBOX NO List the size of each unit (in HP and KW): FORMTEXT ?????Are there procedures in place for staff to help with building evacuation in emergency situations? FORMCHECKBOX YES FORMCHECKBOX NO Please elaborate on those: FORMTEXT ?????Does building have lighted ‘exit’ signs, with emergency exit lighting? FORMCHECKBOX YES FORMCHECKBOX NO Are there any cooking or food service activities at this location? FORMCHECKBOX YES FORMCHECKBOX NO If yes, please explain: FORMTEXT ?????Rating Information What are your Gross Sales / Receipts for the past 12 months? $ FORMTEXT ?????What are your projected Gross Sales / Receipts this policy year? FORMTEXT ?????What is your projected payroll this policy year? $ FORMTEXT ?????Do you use the service of an independent gunsmith? FORMCHECKBOX YES FORMCHECKBOX NO . If yes, does the gunsmith have liability insurance? FORMCHECKBOX YES FORMCHECKBOX NO . If yes, please attach a copy of the Gunsmith’s Certificate of Liability Insurance. Please provide estimated sales for each classification, rounding to the nearest thousand dollars. If you have no sales for a particular classification, indicate that by writing “None” for that classification.The following items can be deducted from gross sales:Sales or excise taxes which are collected and submitted to a governmental division.Freight charges, if charged as a separate item on customer invoices. Classification Estimated Sales/ReceiptsWholesale or Distributor Firearms, Ammunition & Associated Products $ FORMTEXT ?????All Other Products $ FORMTEXT ?????Retail Sales Firearms, Ammunition & Associated Products $ FORMTEXT ?????All Other Products $ FORMTEXT ?????Gunsmithing, (including assemble of firearms) $ FORMTEXT ?????Manufacturing of Reloaded Ammunition $ FORMTEXT ?????Manufacturing of New Ammunition $ FORMTEXT ?????Bullet Manufacturing $ FORMTEXT ?????Accessory Manufacturing $ FORMTEXT ?????Gun Part Manufacturing $ FORMTEXT ?????Firearms Instruction $ FORMTEXT ?????# of Instructors FORMTEXT ?????Ranges/Club (Indoor)$ FORMTEXT ?????Ranges/Club (Outdoor) $ FORMTEXT ?????Restaurant Sales $ FORMTEXT ?????Alcohol Sales $ FORMTEXT ?????Skeet, Trap & Sporting Clays $ FORMTEXT ?????Archery Range (Indoor)$ FORMTEXT ????? Archery Range (Outdoor) $ FORMTEXT ?????TOTAL ESTIMATED SALES / RECEIPTS $ FORMTEXT ????? *Total Sales/Receipts should equal your projected Gross Sales/Receipts Please provide the average number of firearms in your inventory as well as values detail below. Business Personal Property Consists of: Values FORMTEXT ????? FORMTEXT ?????Long guns $ FORMTEXT ?????# NEW IS: FORMTEXT ????? # USED IS: FORMTEXT ?????Hand guns$ FORMTEXT ?????# NEW IS: FORMTEXT ????? # USED IS: FORMTEXT ?????Gun parts$ FORMTEXT ?????Ammunition$ FORMTEXT ?????Powder$ FORMTEXT ?????Sporting goods$ FORMTEXT ?????Property in Transit $ FORMTEXT ?????From gun shows/vendorsProperty off-campus$ FORMTEXT ?????Displays/at gun showsFurniture/fixtures$ FORMTEXT ?????Stock/ Other Retail items$ FORMTEXT ?????Range Machinery/Equipment$ FORMTEXT ?????Other Machinery /Equipment$ FORMTEXT ?????Tenants Improvements Betterment $ FORMTEXT ?????Total Limit of BPP: $ FORMTEXT ????? Deductible FORMTEXT ?????Personal Property of Others $ FORMTEXT ?????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: FORMTEXT ????? # of Lockers FORMTEXT ?????Note: 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 FORMTEXT ????? Dated FORMTEXT ?????Applicant’s Name (please print) FORMTEXT ????? Title FORMTEXT ?????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 FORMTEXT ????? Dated FORMTEXT ?????Producer’s Name (Please print) FORMTEXT ?????PRODUCER’S AGENCY/ENTITY FORMTEXT ????? ................
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