Thank you for considering Cossio Insurance Agency. We strive to give our customers personal service, with the best coverage, at the best rate.  After completing this web page, press the 'Submit' button and your application will be transmitted electronically to our office.  We will contact you upon receipt and if we need any additional information.

About this Application


If you want property coverage please fill out the last two pages. Property includes Building, Contents and Business Interruption. Please use 25% of total sales for Business Interruption. If you are leasing your building you will not need building insurance unless required by your landlord. For contents please use the last page to list a breakdown of those contents.

Insurance information requested: (Does not apply to new business owners )
All of this is absolutely necessary in order to receive a quote. Any missing item is considered an incomplete application and will delay processing your quote request. Please allow 10-20 working days to receive a quote.

Your application will leave our office within 48 hours of receiving all information from you; however, once it leaves our office, it is out of our control and in the hands of the underwriters. IT IS EXTREMELY IMPORTANT TO FILL IN OUR APPLICATION COMPLETELY AND SEND ALL NECESSARY ATTACHMENTS (LOSS RUNS, RENTAL/WAIVER) FOR US TO SEND YOUR FILE TO THE UNDERWRITER.

Thank You, we look forward to helping you with your insurance needs!

FAMILY ENTERTAINMENT CENTER APPLICATION 
All Fields in this section are required.
Corporate Name: Effective Date (mm/dd/yyyy):
Trade Name:
Federal EIN:
Entity Type:
Mailing Address:
Mailing City, State Zip:   
Contact Person: # Years in Operation:
Email Address:
Physical Street:
Physical City, State Zip:   
Telephone: Fax No.:
Annual Receipts $: Annual Payroll $:
Total Acreage of Facility: Sq Ft Bldg Area:
Hours of Operation: Operating Season of Facility:
Average Annual Attendance IALEI Member?: Yes   No
Website:

 

Operations Exposures:

Coin-Op Amusement Equipment
Do this business operate Coin-Op Amusement Equipment? Yes No
Annual receipts:
Number of pieces of equipment:
Number of attendants:
Ownership status of equipment: Own Lease
Are machines properly grounded? Yes No
Do you have non-slip, non-conductive floor covering? Yes No
Do you maintain your own equipment? Yes No


Bumper Boats
Do this business operate Bumper Boats? Yes No
Annual receipts:
Number of pieces of equipment:
Name of manufacturer:
Number of operators:
Height of observation fence:
Max engine horse power:
Are operators at least 10 yrs old or 48" tall? Yes No
Is the water depth 4ft or less? Yes No


Bumper Cars
Do this business operate Bumper Cars? Yes No
Annual receipts:
How many?:
Manufacturer Name:
How Many Attendants?:
Min. Height Requiremnt:
Cars Equipped with Dash & Headrest Pads? Yes No
Type of Seatbelts:
Whell Pads on Steering Wheels? Yes No


Batting/Pitching Cages
Do this business operate batting/pitching cages? Yes No
Annual receipts:
How many?:
Min Age of Participants:
Reduced Injury Factor (RIF) baseballs used? Yes No
Cages enclosed? Yes No
Non-skid surface? Yes No


Coin-Op Rides
Annual receipts:
How many?:
Describe:


Go Karts
Do this business operate go karts? Yes No
Annual receipts:
How many?:
Number of tracks:
Max Speed (mph) :
Number of Attendants:
Seat Belts Req'd? Yes No
Bumper Guards & Roll Bars? Yes No


Attendant Operated Rides
Annual receipts:
How many?:
Describe:


Laser Tag
Annual receipts:
Sq Ft Area:


Bounce Play/Soft Play
Annual receipts:
Describe:


Miniature Golf
Annual receipts:
How many courses?
Number of Holes:
Founts/Waterfalls Equip. w/ Ground Fault Interrupters? Yes No


Driving Ranges
Annual receipts:
How many courses?
Partitions Between Stalls? Yes No


Gift/Pro Shops
Annual receipts:


Food Operations
Annual receipts:
Concessions? Yes No
Cooked on Premises? Yes No
If Yes, Deep Fryer Grill on Premises? Yes No
Prepackaged? Yes No


Room Rentals
Annual receipts:
Type:


Other
Annual receipts:
Type:


Please complete the following, where applicable:

Operations:
1. List memberships other than IALEI:
2. Do you sponsor spoting/social events? Yes No
If yes, please describe:
3. Are any of the following alcoholic beverages served?
Beer Yes No
Wine Yes No
Other Yes No
4. Certificates received from all concessionaires? Yes No
Teams, leagues, etc.? Yes No
5. Do you sponsor any type of competition? Yes No
If yes, please describe:
6. Do you provide any of the following forms of live entertainment?
Live music Yes No
Disc jockey Yes No
Dance floor Yes No
Other Yes No
If other, please describe:
7. Does facility conduct fireworks display? Yes No
8. Have you made operational changes since your last renewal? Yes No
If yes, please describe:


Batting Cage Supplement
Are batting areas clearly marked for left and right-handed hitters? Yes No
Is home plate clearly marked? Yes No
Number of people allowed in batting cage at one time:
Is machine velocity checked and calibrated? Yes No
How are machines checked/calibrated:
Who checks/calibrates machines?
Are records kept? Yes No
If yes, for how long?
What is the maximum speed allowed for machines?
Can hitters alter pitching machine settings? Yes No
Is safety equipment required? Yes No
If yes, describe safety equipment?
Is waiver/release required to be signed by participants? Yes No
If yes, please submit a copy of the waiver/release.


Go-Kart Supplement
Length of track:
Type of track? Slick Dry
Is the dry track fenced? Yes No
Fences meet ASTM F-24 requirements? Yes No
Type of perimeter barrier:
Go-kart manufacturer:
Minimum age requirement:
Minimum height requirement:
Number of single karts:
Number of karts on track at once:
Are there governors on karts? Yes No
Type of seat belt:
Is there an operator cut-off system? Yes No
Number of double-seated go karts:
Maximum speed:
Are track rules clearly & prominently posted? Yes No
Are safety signs clearly & prominently posted? Yes No
Is any racing allowed? Yes No
If yes, please describe
Is gas stored away from track? Yes No
Distance between track and refueling station
Are spectators clearly separated from track? Yes No
Are patrons given waivers? Yes No
* If yes, please attach a copy
* Please provide a drawing of the shape of the track
Kiddie-karts available for rent? Yes No
Age of karts
How often are karts maintained?
Who maintains karts?
Maximum horsepower of any one kart
Can rider adjust kart govenor? Yes No
Can karts be controlled from a remote location? Yes No
If yes, provide location:
Is there a remote control device for emergency slow down or shut down of the karts installed? Yes No
Are the rules explained before operators begin using the karts? Yes No
Are the karts equipped with roller bars and bumper guards? Yes No
Are your employees trained in first aid? Yes No
Are the gas and break pedals color-coded? Yes No


Paintball Supplement
Does this business operate any paintball parks? Yes No

Description of Paintball Operations:
Annual Paintball Receipts:
Annual # Signed Waivers:
Total Sq. Ft. of Playing Field:
Annual Repair Receipts:
Annual Equipment Sales:
Hours of Operations:


Other Information related to Paintball Operations:
1) Are written instructions, procedures & training provided for participants? Yes No
2) What are the Age/Height/Weight limitations for participants:
3) Maximum number of participants per game:
4) Do you have special events, such as Tournaments, Big Games, etc.? Yes No
5) Does equipment meet ASTM standards? Yes No
6) Specify types of air fills used
7) Are safety plugs mandatory? Yes No
8) List protective gear supplied to partipants
9) Average age of Rental Equipment
10) Indicate feet per second used at your location
11) Do you repair/modify equipment sold? Yes No
12) Are products sold either US Made or purchased through a US Wholesaler? Yes No
13) How often is equipment inspected for damages/safety?
14) Is there a scheduled maintenance plan? Yes No
15) How often is equipment changed?
16) Do manufacturers provide Certs of Insurance and are you named as addl. insd? Yes No
17) Are patrons separated by levels of experience? Yes No
18) Are spectators properly protected from the paintball area/field? Yes No
19) What is the ratio of judges to participants?
20) Are patrons who violate the safety rules ejected? Yes No
Paintball / Laser Tag Supplemental
21) Is the facility enclosed or fenced? Yes No
22) Is the facility able to be locked? Yes No
23) Are there any barriers or obstacles? Yes No
If yes, please describe
24) Is hand-to-hand fighting allowed? Yes No
25) Are the games referreed? Yes No
If yes, by whom
26) Are patrons allowed to bring their own equipment? Yes No
If yes, is the equipment and velocity checked? Yes No
If yes, by whom
If yes, how often
27) Are employees trained in first aid? Yes No
28) Is eye protection required? Yes No
If yes, what kind

Please Attach a copy of the safety rules enforced at your location, and a copy of the Waiver of Liability.

Existing Coverages:
Coverage Insurance Company Expiration Date Limits Premium Deductible
General Liability
Umbrella
Workers Comp


Indicate below, the # of Claims and Amount Incurred (paid + reserved) in each of the last 5 years:
Year Number of Claims Total Incurred Amount
2006
2005
2004
2003
2002


* NOTE : Please forward the currently valued loss runs from your Carrier, along with this application. •Mechanical Bull•Bungee Jumping•Skateboarding•Trampolines •Hang Gliding•Sky Diving•Hot Air Balloons•Velcro Jumps •Parasailing•Parachuting•Luge•Tobogganing •Traveling Rides•Movable Inflatables•Roller Rinks•Ice Skating Rinks •Bowling Alleys•Temporary Outdoor•Water Slides•Night Clubs/Disco Mazes Dancing

Warranty
It is hereby understood and agreed that if insurance is issued by virtue of completing this application, the Insurance is only issued on the reliance on the applicant’s warranty of answers to the questions above. If, at the time a certificate/policy is issued and ANY OF THE ABOVE WARRANTIES IS IN ANY RESPECT INCORRECT, INCLUDING CLAIMS OR GROSS RECEIPTS, THE COVERAGE AFFORDED UNDER THE CERTIFICATE/POLICY shall, without notice to the applicant, immediately and automatically cease, & the certificate/policy shall BECOME NULL AND VOID. Warranties will survive a certificate/policy if issued.

APPLICANT:
Name:
Title:
 
PRODUCER (If Applicable):
Name:


Are you interested in getting a property quote? Yes  No