Cossio Insurance Agency Family Entertainment Centers
Property Information
NOTE: Remember not to hit your back button or your refresh button so that you do not
accidentally erase or wipe out any type of information that you have typed in.
Have you made any operational changes since last year:
Yes
No
(Examples: name changes or additional names, new attractions, location changes, etc.) If yes, describe:
Fill in the information below for all New Attractions.
Please complete the following for any operations not previously reported:
How many new operations do you currently own:
Name:
Manufacturer:
Receipts:
Describe
Attraction ht:
Age/ht req:
Name:
Manufacturer:
Receipts:
Describe
Attraction ht:
Age/ht req:
Name:
Manufacturer:
Receipts:
Describe
Attraction ht:
Age/ht req:
Name:
Manufacturer:
Receipts:
Describe
Attraction ht:
Age/ht req:
Name:
Manufacturer:
Receipts:
Describe
Attraction ht:
Age/ht req:
Name:
Manufacturer:
Receipts:
Describe
Attraction ht:
Age/ht req:
Name:
Manufacturer:
Receipts:
Describe
Attraction ht:
Age/ht req:
Name:
Manufacturer:
Receipts:
Describe
Attraction ht:
Age/ht req:
Name:
Manufacturer:
Receipts:
Describe
Attraction ht:
Age/ht req:
Name:
Manufacturer:
Receipts:
Describe
Attraction ht:
Age/ht req:
Loss Information
If you were insured with another Insurance Company in the last 5 years, please provide updated loss runs for that period.
Locations and Values currently insured under Property Policy:
PROPERTY NO. 1
Address:
City:
State:
Zip:
BUILDING
CONTENTS
LOSS OF INCOME
LAST YEAR:
THIS YEAR:
PROPERTY NO. 2
Address:
City:
State:
Zip:
BUILDING
CONTENTS
LOSS OF INCOME
LAST YEAR:
THIS YEAR:
PROPERTY NO. 3
Address:
City:
State:
Zip:
BUILDING
CONTENTS
LOSS OF INCOME
LAST YEAR:
THIS YEAR:
PROPERTY NO. 4
Address:
City:
State:
Zip:
BUILDING
CONTENTS
LOSS OF INCOME
LAST YEAR:
THIS YEAR:
PROPERTY NO. 5
Address:
City:
State:
Zip:
BUILDING
CONTENTS
LOSS OF INCOME
LAST YEAR:
THIS YEAR:
PROPERTY NO. 6
Address:
City:
State:
Zip:
BUILDING
CONTENTS
LOSS OF INCOME
LAST YEAR:
THIS YEAR:
PROPERTY NO. 7
Address:
City:
State:
Zip:
BUILDING
CONTENTS
LOSS OF INCOME
LAST YEAR:
THIS YEAR:
PROPERTY NO. 8
Address:
City:
State:
Zip:
BUILDING
CONTENTS
LOSS OF INCOME
LAST YEAR:
THIS YEAR:
PROPERTY NO. 9
Address:
City:
State:
Zip:
BUILDING
CONTENTS
LOSS OF INCOME
LAST YEAR:
THIS YEAR:
PROPERTY NO. 10
Address:
City:
State:
Zip:
BUILDING
CONTENTS
LOSS OF INCOME
LAST YEAR:
THIS YEAR:
Please make sure that you have completed everything to the best of your knowledge before going to the next page.