Confirmation | Family Fun Center Insurance App

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Company Info
Premises
Operations
Rentals
Abuse
Liquor
Auto
Property
Confirmation

Section 13: Crime Exposures

On premises:
Maximum daily cash: $
Amount overnight: $
Desired crime limit:
Safe? Yes No
What manufacturer:

Section 13B: Additional Interests
#1) Name:
Landlord Loss Payee Mortgagee

Mailing Address

Mailing address:
City:
State:
Zip code:

2) Name:
Landlord Loss Payee Mortgagee

Mailing Address

Mailing address:
City:
State:
Zip code:

In order to process your application we need you to attach the following documents:
Completed Application with all Questions Answered
Currently valued insurance company loss runs for the current policy period plus 5 prior years
Resume (New Business Only)
Business &Financial Plan (New Business Only)
Diagram of premises
Equipment/Attractions List
Safety Rules
Waiver
Daily Safety Checklist
Lease Agreement
Evacuation Diagram & Procedures

Section 14: Signature
(Applies to all parts of this application and attachments submitted) It is hereby understood and agreed that if insurance is issued by virtue of completing this application and any applicable supplemental applications, the Insurance is only issued on the reliance on the applicant’s warranty of answers to the questions above and on any such supplemental applications. 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.
Person Applying:
Date Submitted:

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