family entertainment center application - 877-792 … entertainment center application ... is this...

Family Entertainment Center Application

Business name:

Mailing address:

Federal ID #:Phone # of facility:

Website address of facility:

DBA:

Other:

Additional Insured's /Certificate Holders and mailing address ( Please specify their interest in the operation. Example - Landowner, vendor, investor, etc.)

Type of Entity (Corp. Individual, Partnership, Joint Venture, LLC)

Contact Person of Facility:

Phone:

Owner of Facility:

Cell:

Email:

Title:Phone:

Cell:

Email:

Name: Name:

Is the facility family owned and operated:

Yes No Is this business a franchise:

Yes No

Location address:

State: Zip Code:

State: Zip Code:

(City)

(City)

(If more then one location, please use another application)

BIA Insurance Services Freeland, Mi 48623 877-792-5800

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BIA

Policy Information

Operations Receipts:

Arcade

Batting cages

Bumper cars

Bumper boats

Concessions

Driving range

Go-karts (gas)

Go-karts (electric)

Go-karts (kiddie, rookie)

Rock climbing wall

Laser tag

Water wars

Other (please write in activities and receipts if not listed)

Total

Prior Carrier Limit of Liability Premium Deductible

Expiring

Expiration date of policy:

Has your policy ever been canceled / Non renewed: If yes, explain:

Please attach Five year currently valued / updated loss runs from prior carriers. If any claim activity please give details below:

( If more than one location, please fill out sheet for each location ) ( if this is a water park, please fill out water supplement)

Miniature golf

Note: For new owner/operators, we require a resume and business plan prior to quoting.

Yes No

Attendant operated rides

Kiddie rides

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Water Slides $


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Facility Information Part 1

How long has the owner had this facility:

Is facility open year-round: to (If no, operational months )

Days open per week: Hours:

Are any alcoholic beverages served or allowed on the premises:

Is the entire facility fenced off:

Do you provide day care or babysitting services:

Do you have an employee handbook:

# of staff on a average day:

Do you use any waivers: (If so, please attach a copy of waiver)

# of employees:

# of years experience:

Do you provide after school and/or summer programs:

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Do all employees wear uniforms or same apparel: Yes No

Do any employees attend any Industry Training Sessions: Yes No

Percentage of full time employee turnover:

What is the avg. age of all equipment:

Are security cameras used at this facility:

Do you have any overnight activities or events: Yes No

If yes, do they cover the:

full time: Part time:

Is there a full time maintenance person:

How are maintenance records kept:

Yes No

Written: Electronic:

Do you contract or employ any security:

(If yes, are they armed:)

If yes, are they contracted

Are they off duty police officers: Yes No

Yes No

or employed:

Yes No

Entire: or partial: Facility:


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How many fire extinguishers:

Do you have a first aid kit(s):

Have employees been trained to use fire extinguishers:

Location(s):

Any employees CPR / first aid certified:

Are they all charged:

How many:

Facility Information Part 2

Are the rides inspected by a state agency:

Is the facility inspected by the fire dept:

Any other type of inspection(s):

Do you have an employee safety program:

Do you use a pre-opening check list for the facility daily:

Yes No

If yes please explain:

If yes how often:

If yes how often:

If yes, please specify:

Inspections

Safety/First Aid

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Have you ever been cited for violations or law of ordinances: Yes No

Yes No

Is there more then one public exit in the main building structure: Yes No

Do you have fireworks display:

If yes, are the displays managed by employees or contracted out:

Yes No

Do you have staff meetings: Yes No (If yes, how often)


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Go-Karts

Track Information Kart Information

Name or type of track:

Surface of track:

Barrier around track:

Type of fence :

# of karts owned:

Speed of karts:

Height/age requirements:

Rules posted:

Height marker:

Karts have belts/harness:

How are belts checked:

# of employees at track:

Height of fence:

How many fire extinguisher are in the track area:

Helmets available:

Are waivers used:

Track indoor/outdoor:

Gas or electric:

Manufacturer:

Padded steering:

Belt guard covers installed:

Cut off switches installed:

Bumpers on karts:

Remote shut offs used:

How is gas stored:

First aid kit in the pits:

Maintenance Shop

Is any gas stored in shop:

Maintenance logs per kart:

Karts kept in shop overnight:

Fire extinguishers in shop:

How many fire extinguishers Are in the pit area:

Maintenance logs per day:

Full time maintenance person:(if yes, attach copy)

Type of Barrier:

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Maintenance logs are: Written: Elec:

Positions of employees:

(Please make copies if more then one track)


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Arcade

# of Games: Redemption area:

Type of flooring: Wires exposed:

Batting Cages

Cage

Speed

Helmets required:

# of attendants at batting cages:

Are rules clearly posted:

Is the batters box and home plate clearly marked:

1 2 3 4 5 6 7 8 9 10

Manufacturer of machine:

Are cages completely enclosed with netting:

# of participants in cage at one time:

Gas or electric:

Are machines maintained daily:

Is a maintenance log book kept:

Bumper Boats

# of attendants at bumper boats:

# of boats: Manufacturer:

Age/height requirements:

Size of pool: Length Width Depth


Are props under the boat protected:

Are life vest available:

Is pool fenced in:


Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No


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BIA

Bumper Cars

# of attendants:


Are machines maintained daily:


Gas or electric:# of cars: Manufacturer:

Age/Height requirements:

Size of area: Length: Width:

Is area fenced in:

Are cars equipped with steering pads and head pads:

Are cars equipped with seat belts:

Concessions

Types of food sold:

Is there an automatic ansul system protecting cooking/fryer surfaces:

Do you use deep fryers:

Do you use a grill:

Do you have a fire extinguisher nearby:

Driving Range

# of tees:

Fencing or netting:

Are there dividers:

More then one level:

Are attractions exposed:

Rules clearly posted:

Miniature Golf

# of holes:

Walkways well lit:

Area fenced in:

Attendants on duty:

Is there water:

Rules clearly posted:

Sq. footage:

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No Yes No


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Laser Tag

Square footage: Avg. # of employees:

# of people per session:Minutes per game:

How many emergency exits:

Is there more than one level:

Are there any stairs:

Are the exits locked from the inside:

Are the exits well lit:

Manufacturer:

Climbing Wall

Height of wall:

What type of harness is used:

# of employees: How many climbers at a time are allowed:

Is a maintenance log kept:

What are the age, height, and weight restrictions:

How are free falls prevented:

Yes No

Yes No

Yes No

Yes No

Yes No Auto Belay: Yes No

Inflatables (Bouncers, Combos, Slides, Obstacle course, Joust, Sumo, Bungee run, Etc...)

Name Manufacturer Serial #

(Additional Space on Page 10)


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Kiddie Rides

Kiddie rides - coin operated: # of rides:

List ride(s):

Kiddie rides - non coin operated: # of rides:

List ride(s):

Kiddie Inflatables: # of Inflatable(s):

Name of inflatable(s):

Pony rides: # of ponies:

Are ponies tethered to a sweep:

Is the area fenced in:

Do you give any hand led pony Rides:

Soft play: # of attendants at soft play:

Manufacturer: What are the age requirements:

Is the soft play multiple levels:

What is the square footage of the soft play area:

Kiddie Rides General Questions

Are there attendants at each activity:

Are the rides checked daily:

Is there a maintenance log kept:

How are the rides secured overnight:

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No


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Mechanical / Attractions / Additional Inflatables / Other Rides

Name Manufacturer Serial #

Yes No

Kiddie Adult

How often are these amusements inspected: By whom:

Does a state agency inspect these amusements:

Are the Manufacturing guidelines followed for Maintenance and operating the rides:

How are rides secured when not in use:

Yes No


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Additional Information/Comments

Important Notice

I DECLARE THAT THE STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND TRUE TO THE BEST OF MY KNOWLEDGE AFTER REASONABLE

INQUIRY

Any person who knowingly and with intent to defraud any insurance company or another person submits an application for insurance or statement of claim containing any materially false information, or conceals for purpose of misleading, information containing any material fact thereto, commits a fraudulent act that is subject to criminal and substantial civil penalties. I agree that any intentional concealment or misrepresentation of a material fact concerning this insurance or the subject thereof may void any policy issued.

Applicant Signature:

Producer Signature:

Producer name and address:

Date

Date:

Title


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Lyle Brewster 5435 W.Freeland Road Freeland, MI 48623

BIA

family entertainment center application - 877-792 … entertainment center application ... is this...

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