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SCOTTSDALE INSURANCE COMPANY

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					            SCOTTSDALE INSURANCE COMPANY
                              SKATING APPLICATION
                                   GENERAL INFORMATION

RINK NAME ________________________________________________________________________________

CORPORATE NAME _________________________________________________________________________

MAILING ADDRESS _________________________________________________________________________

CITY ____________________   STATE ______     COUNTY ____________________ ZIP ______________

LOCATION ADDRESS (IF DIFFERENT) _________________________________________________________

CITY ____________________   STATE ______     COUNTY _____________________ ZIP ______________

RINK PHONE #: AREA (____) _________________ OFFICE PHONE #: AREA (____) ____________________

HOME PHONE #: AREA(____) _________________ FAX #: AREA (_____) ___________________________

APPLICANT IS: _____ INDIVIDUAL _____CORPORATION _____PARTNERSHIP _____FRANCHISE

SOCIAL SECURITY OR CORPORATE TAX I.D. NUMBER: __________________________________

DO YOU OWN?            Y       N     OR DO YOU LEASE THE PREMISES?          Y       N

HOW MANY YEARS OF EXPERIENCE DO YOU HAVE IN THE SKATING INDUSTRY? ________________

ARE YOU A MEMBER OF USAC/RS, NIHA, ISI,      PLEASE LIST _______________________________________


IS THIS A NEW OPERATION?        Y       N YEARS IN BUSINESS AT THIS LOCATION _____________

1. LIST OTHER LOCATIONS OWNED OR OPERATED:
        1.____________________________________         2._____________________________________

        3. __________________________________          4. _____________________________________

2. BUILDING AND CONTENTS DATA                        3. ANNUAL GROSS RECEIPTS

    A. NUMBER OF STORIES ____________________        SKATING       $__________________________

    B. OTHER OCCUPANCIES ___________________        SNACKBAR       $__________________________

    C. NUMBER OF SKATING SURFACES__________          ALCOHOL       $__________________________

      length_______X width_______=_______sq ft      VIDEOS         $___________________________

      length_______ X width_______=_______sq ft     DANCING        $__________________________

.   D. SURFACE COMPOSITION _________________        BINGO          $__________________________

    E. TYPE OF OTHER FLOOR SURFACES                 OTHER          $__________________________

       _______________________________________      TOTAL          $__________________________

    DATE LAST RESURFACED___________________

    F. AGE OF BUILDING ________________________
       IF OVER 25 YEARS OLD, YEAR UPDATED           ELECTRICAL ____________ HVAC _________
                          PHYSICAL PLANT INFORMATION



WRITTEN EMERGENCY PLAN         Y       N       BEING DEVELOPED
BUILDING INSPECTION CHECKLIST        Y               BEING DEVELOPED
SKATE MAINTENANCE LOG         Y         N
FIRE ALARM         Y       N
GUARD DOGS           Y        N
BURGLAR ALARM/MOTION DETECTOR             Y       N
NUMBER OF POLICE RESPONSES TO PREMISES IN LAST 3 YEARS? ______________
OUTSIDE SECURITY      Y   N
EMERGENCY EXITS      Y N HOW MANY? ____ ARE THEY LOCKED?       Y     N
PANIC BARS ON EXIT DOORS      Y       N
EMERGENCY LIGHTS      Y   N HOW OFTEN TESTED/SERVICED? _______________
PARKING LOT     Y    N YEAR LAST RESURFACED __________________
CERTIFIED FIRST AID PERSONNEL    Y     N HOW MANY PER SESSION? _____
BARRIER SEPARATING SKATERS FROM SPECTATORS      Y    N HEIGHT ________
DO YOU HAVE A DEEP FRYER OR GRILL ? Y     N
APPROVED BY FIRE MARSHAL      Y    N
HOW OFTEN IS THE SYSTEM CLEANED? _________________________
NAME OF SERVICE CONTRACTOR __________________________________________

MAXIMUM OCCUPANCY RATE ___________ PER FIRE CODE

                               RINK USE INFORMATION

PERCENTAGE OF USE DURING YEAR: OPEN SESSION _____% PRIVATE PARTIES ____%
MAXIMUM NO. OF SKATERS PER FLOOR GUARD______
MAXIMUM CAPACITY OF RINK ________
SPECIAL PROGRAMS - DESCRIBE
____________________________________________________________________________________

DANCING      Y     N    SKATING COMPETITIONS        Y     N
IF YES, EXPLAIN____________________________________________________________________
SPONSORING OR SANCTIONING ORGANIZATIONS           Y    N    IF YES CIRCLE NAMES
USAC/RD, USA ROLLER HOCKEY, ISIA, HIHA, USFSA, NRHA, RHIA, OTHER_______________

FIGURE SKATING       Y     N                 EXERCISE CLASSES     Y      N
SPEED SKATING        Y     N                 IN-LINE SKATING      Y      N
HOCKEY               Y     N                 SANCTION CARDS       Y      N

DO YOU CONDUCT THE FOLLOWING ON YOUR PREMISES?
EQUIPMENT SALES  Y    N   EQUIPMENT RENTAL Y N PREMISES         OUTSIDE
REPAIR SERVICE   Y    N   PICNIC FACILITIES      Y    N
DAY CARE         Y    N   BUS, CAR, OR TRANS. SERVICE    Y      N
SNACK BAR        Y    N   SALE OF ALCOHOLIC BEVERAGES        Y      N
MINIATURE GOLF   Y    N   OTHER         Y        N
VIDEO GAMES      Y     N  EXPLAIN OTHER _____________________________
LAZER TAG        Y    N
                                      STAFFING INFORMATION

TOTAL NUMBER OF STAFF ______ FULL TIME(40 hours)_____ PART TIME ______
MINIMUM AGE OF GUARDS ______

OWNER’S NAME ___________________________________________________________
MANAGER’S NAME _________________________________________________________




                                EXPIRING INSURANCE CARRIER
                            PLEASE COMPLETE FOR LAST FIVE YEARS

YEAR            COMPANY                          LIABILITY LIMITS         DEDUCTIBLE PREMIUM

20___           _____________________            _________________        ___________      _________
20___           _____________________            _________________        ___________      _________
19___           _____________________            _________________        ___________      _________
19___           _____________________            _________________        ___________      _________
19___           _____________________            _________________        ___________      _________

HAS INSURANCE EVER BEEN REFUSED OR CANCELLED?              Y       N
                              IF YES, PLEASE DESCRIBE
_____________________________________________________________________________________
_____________________________________________________________________________________
 __________________________________________________________________________________

                              CLAIMS AND INCIDENT REPORT DATA

AVERAGE NUMBER OF INCIDENTS AND/OR CLAIMS FOR THE LAST THREE(3) YEARS
_______________ PER ______________WEEK ____________MONTH ___________YEAR

List any CLAIMS and LOSS HISTORY for the last three (3) years. To your knowledge how much
money has been paid out on your behalf in each of the last three years as a result of accident, lawyer
demands, etc.

PRIOR YEAR 1 ______________________________________________________________________
PRIOR YEAR 2 ______________________________________________________________________
PRIOR YEAR 3 ______________________________________________________________________

On a separate sheet of paper give a full description of EACH loss over $5,000.
                                              COVERAGES REQUESTED

PROPOSED EFFECTIVE DATE__________________________


LIMIT OF LIABILITY:                                                    LIABILITY DEDUCTIBLE

$300,000/600,000                                   $1,000                          DEDUCTIBLE
$500,000/1,000,000                                 $2,500                          DEDUCTIBLE
$1,000,000/1,000,000                               $5,000                           DEDUCTIBLE
$1,000,000/2,000,000


WOULD YOU LIKE TO PREMIUM FINANCE?                                       Y           N

ADDITIONAL INTERESTES?                              Y             N

________ CERTFICATE HOLDER                      ________ ADDITIONAL INSURED                        _______ LANDLORD


__________________________________________________________________________________
      (NAME)                                           (PHONE)
__________________________________________________________________________________
      (STREET ADDRESS)           (CITY)        (STATE)              (ZIP)

THIS APPLICATION IS SUPPLIED AS A MEANS OF ACQUIRING INFORMATION. IT IS NOT A BINDER
AND NOTHING HEREIN CONTAINED SHALL BE CONSTRUED AS AN AGREEMENT TO BIND
INSURANCE OF ANY KNID OR DESCRIPTION.

                                                         WARRANTY
It is hereby understood and agreed that if insurance is issued by virtue of completing this application, the insurance is only issued
on the reliance on the applicant’s warranty of the accuracy of answers to the questions above. Warranties will survive a
certificate/policy if issued.

APPLICANT (PLEASE PRINT OR TYPE)                          ______________________________________________

___________________________________________________________________________________

    (SIGNATURE OF APPLICANT - MANDATORY)         (TITLE)           (DATE)
___________________________________________________________________________________
  (SIGNATURE OF PRODUCER COMPLETING APPLICATION - IF APPROPRIATE)

PRODUCER: ______________________________________________________________________

				
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