Escape Room Insurance Questionnaire

Escape Room Insurance Questionnaire
Applicant's Name:*
Address:*
Mailing Address
Address (cont.):*
Mailing Address - continued
Contact:*
Email*
Telephone:*
Website
Fax:
Applicant is:

IndividualPartnershipCorporationOther (specify)Other
Current Carrier:
Expiration Date:
Limits: ($)
Premium: ($)
Deductible: ($)
GENERAL INFORMATION
1. Describe your operations including a complete list of activities. Please attach a flier if available.
2. What are total annual receipts?
3. Price of admission
4. Average number of visitors annually?
5. Maximum number of players?
6. Are you open:

Year roundSeasonally
6a. Hours of Operation:
7. Number of years in business under present management:
8. Does applicant own or lease premises?

OwnLease
8a. Other occupancies?
9. What is your annual payroll (excluding owners, officers, and support staff)?
9a. Number of owners/officers
9b. Please indicate number of employees:

Full-Time Part-Time

Number
9c. What pre-employment screening is used? Please explain:
10. Additional Locations: (if different from mailing address above)
11. Do you require participants to sign a waiver of liability? (If yes, please attach a copy.)

YesNo
12. What is the minimum age allowed?
12a. If under 18 years old, do parents or guardians have to sign the waiver also?

YesNo
13. Do you ever hire sub-contractors/independent contractors that carry their own insurance?

YesNo
13a. If yes, please describe:
13b. If yes, are certificates of insurance provided?

YesNo
13c. Do subcontractors name you as additional insured on their policy?

YesNo
13d. Total Cost ($)

	Full-Time	Part-Time
Number

	Amount ($)
Limit of Liability
Comprehensive Deductible
Collision Deductible

UMBRELLA AND WORKERS' COMPENSATION INSURANCE
1. Do you need a Commercial Umbrella?

YesNo
1a. If yes, limit of liability needed? ($)
2. Do you need Workers Compensation? (If yes, please contact Kevin Morency.)

YesNo
SIGNATURE
The information I have provided is true and accurate to the best of my knowledge. I have not willfully concealed or misrepresented any material fact(s) or information. I understand completion of this questionnaire does not compel the company to provide coverage.
Signature

Clear
Or Enter Your Full Name as Signature:
Date:
Questions? 877-244-9090
Kevin Morency | kmorency@morencyinsurance.com

Morency & Associates, Inc.
141 New Shackle Island Rd, Hendersonville, TN 37075

https://familyfuninsurance.com/escape-room-insurance/
Should be Empty:

	Yes	No
8. Emergency lighting?
9. Surveillance cameras?
10. Fire Alarm?
11. Is Assumption of Risk signage placed throughout facility?
12. Is there an emergency evacuation plan, medical emergency plan, disaster/crisis plan?
13. Are all exits from the building clearly marked?

	Yes	No
10. Are fire extinguishers on site? (Valid inspection tag required)
11. Are there smoke detectors?
12. Is there a sprinkler system?
13. Did the fire department conduct an inspection?
14. Do you have a certificate of occupancy?

	Yes	No
5a. Abuse and Molestation?
5b. How to recognize the signs of abuse?
5c. What to do if an individual reports someone molested him/her?

	Building Description (Age & Construction)	Building Limit ($)	Content Limit ($)
Building 1
Building 2

	Year	Make	Model	Value to Insure For ($)
Item 1
Item 2
Item 3

	Tenant	Operation/Relationship
Tenant 1
Tenant 2

	Vehicle Make	Vehicle Model	Cost New ($)	Year
Vehicle 1
Vehicle 2
Vehicle 3