POLICY RECOMMENDATIONS(Please check any you are interested in)
General Liability
Accident Medical
Inland Marine
Worker's Compensation
Commercial Auto
EPLI
Hired & Non-Owned Auto
Umbrella
Abuse/Molestation
Cyber Liability
Submission Requirements
1) Copy of Waiver
2) Diagram of Premises
3) Copy of rules of play
4) Signed safety rules
Section 1: COMPANY INFORMATION
How did you hear about us?
Choose One
Bing
Customer Referral
Google
Manufacturer
Other
Postcard
Social Media
Trade Show
Yahoo
Business Name:
Name of Facility:
Contact First Name:
Last name:
Phone number:
Cell number:
Fax number:
Email address:
Website:
Date of Birth:
Mailing Address
Address/PO Box:
City:
State:
Zip code:
Physical Address
Street Address:
City:
State:
Zip code:
Business type?
Corporation
Partnership
Individual
Year business started:
FEIN/SS#:
Do you ever process payment cards?
Yes
No
Estimated annual number of payment card transactions:
Desired Effective Date:
Detailed operations descriptions:
Desired Effective Date:
Create Password (this will allow you to access you application at a later time) :
Submit
Please make sure that you have completed everything to the best of your knowledge before going to the next page.
