Best Shot Gun Shop/Dealer/Range Insurance Application

Transcription

1 Best Shot Gun Shop/Dealer/Range Insurance Application General Information Business Name: Principal Contact: FEIN#/SSN# Location Address: Location City: County: State: Zip: Contact Number: Fax Number: Website: www. Address: Business Entity: Corporation Partnership Individual LLC Other Effective Date: Any other Business from this location: Name and description: Do you have separate insurance for this business: How long have you been a licensed firearm dealer:? What type of firearm license do you hold (provide copy): Have you ever been cited under your firearm s license If yes, please describe: Property Section Is building owned or leased? Building Limits: Business Personal Property Limits: Security measures. Fire Alarm Central Local Burglar Alarm Central Local Smoke Detectors Battery Hardwired Doors: Metal Glass Frame Windows and glass doors have bars? Do you have a gun safe? If yes, describe (type, class, manufacture): Describe other protection devices: Age of building: If over 10 years old, list updates to plumbing, heating/ac, Wiring, roof, etc Does the building have other occupancies? If yes, describe:

2 Are there additional locations to be insured? Address: County: State: City: Zip: Description of use: Is building in city limits? _ Is the building 100% sprinklered? _ What is the distance to the nearest fire hydrant: Management Years in business: Years Years at current location: Years Do you have written safety policies, procedures, or rules for staff/employees and/or shooters? Is a public address system used that all shooters can hear? Are first aid kits available on the range? Number of employees with First Aid Certification training? # Tournaments/Special events/spectator Special Events being conducted? If yes, describe: Revenue Estimated gross revenue for next 12 months: Sales by mail orders: Sales by internet: Receipts from: New gun sales Used gun sales Consignment sales Archery Equipment Factory Ammo Reloaded Ammo Gunsmithing/gun repair # Of Gunsmiths Payroll for Gunsmiths Bowsmithing Firearm Range Archery Range *Other sporting goods *Rental equipment **Off site gun sales Provide details of type of equipment: Participation in gun shows off premises, provide the number of times a year:

3 Operations Independent gunsmith services used? If yes, do they carrier their own insurance (certificate required)? All firearm products purchased from U.S. manufactures or distributors? If no % directly imported by foreign company. % purchased from foreign wholesaler/distributor. If no, and you are a direct importer, are you named on a U.S. Foreign Manufacture s or importer s insurance policy for vendor s liability coverage? (Provide copy) Wholesalers/Distributors, are you named on a U.S. or foreign manufacture s or Importer s insurance policy for vendor s liability coverage? Total value of retail inventory: $ Total value of firearms inventory: $ Average number of guns in your inventory: NEW Used or Consignment Total # Total # Rifles # Rifles # Shotguns # Shotguns # Muzzle Loaders # Muzzle Loaders # Handguns # Handguns # Do you carry black powder? If yes, estimated pounds in inventory? If yes, storage/handling in compliance with federal, local and state regulations? Do you sell hand loaded ammo? Range Operations Indoor Outdoor Number of Pistol lanes: # # Number of Rifle lanes: # # Number of Archery lanes: # # Number of Test Only lanes: # # Maximum distance shoot: Is range in compliance with standards set by: (IBO, NFAA, NRA, NSSF, etc.) list: Does range have age restriction :(describe) Supervision on duty at all times? Number of supervisors: # Are all range supervisors certified? Are rules of the range clearly posted? Are lessons provide? If yes, provide qualifications of instructors:

4 Do you have club membership? Is range open to the public? Do participants provide information about person, age, name, shooting experience, etc (provide a copy) Do shooters sign a release/waiver of liability? (provide copy) Is eye and hearing protection mandatory? Are shooters, own guns inspected? By whom: Workers Compensation Any Losses in past 4 years? If Yes Date: Description: Amount Paid Date: Description: Amount Paid NCCI Experience Modification (if you have one) Estimated Payrolls: # of Employees Retail Sales: Gun Smithing: Clerical: Other: Do you Supply an Employee Handbook: Is there a Safety Manual Remarks:

5 Prior Carrier Information Last Year Two Years Ago Three Years Ago Insurance Carrier Premium The above information is as true and accurate to the best of my knowledge. I have not misrepresented or willfully concealed any fact(s) or information. I understand that this is not a condition of insurance by filling out this questionnaire, but only a means to obtain a quote for insurance. Applicants Signature Producers Signature Date Date Items needed to provide the correct program and obtain all discounts available: Brochures used Website: www. Waivers Safety Procedures Shooter Questionnaire/Club membership application Insurance company loss runs for past three years, or the below Statement of know known losses, signed and dated. Copy of your FFL license(s) Certificates of insurance form gunsmith, foreign manufactures, or importers. Loss History STATEMENT OF NO KNOWN LOSSES I, on behalf of, (Insured s Principal Name) (Insured s Business Name) Confirm we have had no claims in the last five (5) years. Further, it is Confirmed that we have no knowledge of any accidents or incidents which May give rise to a claim in the last five (5) years. Any exceptions to this statement are to be described in the box below. Principal Signature: on this date EXCEPTIONS TO THE ABOVE STATEMENT Date Description Amount Paid/Reserved