Rage Room

1

Facility:

Indoor

Outdoor

2

Email

example@example.com

3

Does the applicant operate any other operations at this location?

Yes

No

4

Description of Business:

5

Does the applicant have separate insurance for this operation?

Yes

No

6

Is named insured an:

7

Years in this business:

8

Number of Employees: Part Time

9

Number of Employees: Full Time

10

Annual Payroll:

11

Are independent contractors ever used to operate?

Yes

No

12

If yes, what are the estimated annual costs for such labor? $

13

Operation is:

Fixed site only – provide complete address

Mobile – list ALL states where operation anticipated

14

Do you ever allow free sessions?

Yes

No

15

If yes, explain under what circumstances and approximate number per year:

16

Prior General Liability Insurance Company:

17

Expiration Date:

Date

18

Premium:

19

Describe all claims arising out of your entertainment equipment for the past 4 years:

20

Does the facility have any age restrictions?

Yes

No

21

If yes, please describe:

22

Number of rooms:

23

Types of items inside:

24

Is an employee on duty at all times?

Yes

No

25

Are any employees first aid certified?

Yes

No

26

Are waivers mandatory?

Yes

No

27

Please provide a copy.

Yes

28

Is an employee that monitors the rage room on duty at all times?

Yes

No

29

Max ratio of employees to rooms:

30

Are employees trained to strictly enforce all rules and regulations, even if it means stopping a session early or refusing a session to a customer?

Yes

No

31

Does the applicant have written rules prominently displayed?

Yes

No

32

Estimated number of annual participants:

33

What tools or items are used or allowed for customers to use to smash?

34

Will all the walls and floors be padded?

Yes

No

35

Are the rooms soundproof?

Yes

No

36

Do you limit the number of participants allowed in the room?

Yes

No

37

If yes, how many?

38

What safety equipment are participants required to use?

39

Will all rooms be monitored by video/audio?

Yes

No

40

Are participants required to sign a waiver of liability before participating in any session?

Yes

No

41

No one under the age of 18 can participate without the presence of their parent or legal guardian, and such parent/legal guardian is required to sign a waiver of liability for that person.

Yes

No

42

Participant is participating at their own risk, and neither the owner nor operator is responsible for accident or injury to any person arising out of their participation.

Yes

No

43

Individuals with pre-existing conditions such as back, neck, leg, or arm injuries are not permitted to throw. However, the operator is not responsible for determining the physical condition or ability of any person.

Yes

No

44

Participants may request that the session be stopped at any time.

Yes

No

45

Does the operator check photo ID to verify participant identity and age?

Yes

No

46

Are waivers signed in the presence of the operator or other attending employee?

Yes

No

47

How long are signed waivers retained?

48

Where are they stored?

49

Does the operator verbally ask about pre-existing injuries and, if any, refuse the session?

Yes

No

50

Is the liquor license in the applicant’s name?

Yes

No

51

If no, what is the name on the license and their relationship to the applicant?

52

Liquor License Number:

53

Class of License:

54

Is the liquor service subcontracted to a third party?

Yes

No

55

If yes, provide the limits of liability maintained by the subcontractor:

56

Is the applicant listed as an additional insured under subcontractor’s liquor liability coverage?

Yes

No

57

Is contingent liquor liability coverage requested by the insured?

Yes

No

58

Has the applicant’s liquor license ever been revoked or suspended?

Yes

No

59

If yes, explain:

60

Has the applicant incurred claims for liquor liability during the last three years?

Yes

No

61

If yes, explain:

62

Has any insurer cancelled or non-renewed coverage during the last three years?

Yes

No

63

If yes, explain:

64

Has the applicant ever been fined by Alcoholic Beverage Control or other government regulator?

Yes

No

65

If yes, explain:

66

Type of beverages sold:

67

Are patrons allowed to carry alcoholic beverages onto the premises?

Yes

No

68

Does the applicant exercise the right to search and seize contraband items?

Yes

No

69

If yes, how does the applicant notify the public of this?

70

Does the applicant maintain security personnel at entry checkpoints?

Yes

No

71

If yes, what type?

72

Are the alcohol sales and consumption contained within one fixed site, or are booths/stands located throughout the event site?

73

Number of servers used:

74

Are they professional servers?

Yes

No

75

If yes, explain:

76

Are they volunteer servers?

Yes

No

77

If yes, explain:

78

Do the servers receive any type of alcohol awareness training?

Yes

No

79

Has any insurer cancelled or non-renewed coverage during the last three years?

Yes

No

80

Median age of liquor customers:

81

Are minors allowed to enter the location where alcohol is being served?

Yes

No

82

If yes, how is underage consumption of alcohol prevented?

83

Explain how IDs are checked:

84

Are uniformed police officers present at the site of alcohol sales?

Yes

No

85

Are undercover police officers present?

Yes

No

86

Are private security officers present?

Yes

No

87

Average number of officers present at site:

88

Are rules and regulations clearly displayed for patrons to view?

Yes

No

89

If yes, explain how and where they are displayed:

90

Is there a limit placed on the quantity of alcoholic beverages purchased at one time?

Yes

No

91

If yes, explain:

92

Is the parking area patrolled to prevent intoxicated drivers from leaving the premises?

Yes

No

93

If yes, explain:

94

Is there any type of designated driver program?

Yes

No

95

If yes, explain:

96

Are alcohol servers trained in documented responsible alcohol serving techniques (e.g., TIPS, TAM, RAMP, BEST, etc.)?

Yes

No

97

Does the applicant ever permit employees who serve liquor to consume alcohol on the job?

Yes

No

98

Does the applicant ever permit employees who serve liquor to consume alcohol after their shifts?

Yes

No

99

Is the building:

100

Please review building security measures listed below:

101

Is the alarm UL listed or approved?

Yes

No

102

Smoke Detectors:

103

Doors are:

104

Do windows and glass doors have metal bars?

Yes

No

105

Describe other protection measures: (safes, deadbolt locks, metal bars, crash barriers in front of building, fire extinguishers, etc.)

106

If the applicant’s building is more than ___ years old, what year was the last time the wiring, plumbing, and HVAC (heating & cooling) were updated and/or serviced?

107

Does the building have other occupancies?

Yes

No

108

If yes, describe:

109

Are there any additional locations to be covered?

Yes

No

110

If yes, please provide complete address and description:

111

Are all activities and locations to be covered in full compliance with applicable federal, state, and local regulations?

Yes

No

112

Is the building within city limits?

Yes

No

113

Is the building within city limits?

Yes

No

114

What is the distance to the nearest fire hydrant?

115

Other activities conducted on the premises:

116

Limits desired:

Building

Contents

Improvements

Loss of Income

117

Estimated Gross Revenue for the Next 12 Months:

118

Revenue from Axe Admissions:

119

Other Revenue (please describe):

120

Last Year - Insurance Carrier

121

Last Year - Limits of Liability

122

Last Year - Premium

123

Two Years Ago - Insurance Carrier

124

Two Years Ago - Limits of Liability

125

Two Years Ago - Premium

126

Three Years Ago - Insurance Carrier

127

Three Years Ago - Limits of Liability

128

Three Years Ago - Premium

129

Type a question