Family Entertainment Center Quick Quote Form

Please complete the following form to receive your quick quote premium indication.

Please include all information pertaining to the operations of your center.

Contact Information

Corporate Name *

Contact Name *

Phone *

Email *

Mailing Address

Street

City

State

Zip

Facility Address is same as mailing address? YesNo

Facility Address

Street

City

State

Zip

Covered Operations

Please list the annual receipts for each operation your facility provides:

	Do you have?	Estimated Receipts
Coin-Op Amusement Equipment	YesNo	$
Bumper Boats	YesNo	$
Bumper Cars	YesNo	$
Batting/Pitching Cages	YesNo	$
Coin-Op Rides	YesNo	$
Go Karts	YesNo	$
Attendant Operated Rides	YesNo	$
Lazer Tag	YesNo	$
Bounce Play/Soft Play/Indoor Inflatables	YesNo	$
Minature Golf	YesNo	$
Driving Ranges	YesNo	$
Gift/Pro Shops	YesNo	$
Food Operations/Concessions	YesNo	$
Alcoholic Beverages	YesNo	$
Room Rentals	YesNo	$
Climbing Walls	YesNo	$
Bowling	YesNo	$
Paintball	YesNo	$
Bungee Trampoline	YesNo	$
Inflatable Rentals	YesNo	$
Water Slides	YesNo	$

Other Operations

Please desribe any other operations that your facility provides:

Name of Activity/Operation

Description

Receipts$

Current Liability Information

	Insurance Company	Exp. Date	Limits	Premium
General Liability				$
Umbrella Liability				$