General Information

Named Insured:
Contact Name:
Mailing Address:
Telephone:
Fax:
Email:
Insured is:	Individual Partnership Corporation Other:
Expiration date:	(../YYYY)
Expiring Policy Premium:
Current Member of BPAA? Yes No
Do you desire a finance plan? Yes No
Number of years in business:

Property Section

Location name & Address: Building Value* Business Personal Property** Sales (Annual) Liquor Sales (Annual) Inside City Limits: Yes No Sprinklered: Yes No Year built: # Stories: Basement: Yes No Construction: Square footage: # of Signs/Value Location name & Address: Building Value* Business Personal Property** Sales (Annual) Liquor Sales (Annual) Inside City Limits: Yes No Sprinklered: Yes No Year built: # Stories: Basement: Yes No Construction: Square footage: # of Signs/Value

^* Building Value should include improvements & betterments, fencing, lights, permanently installed fixtures and machinery such as pinsetters, automatic scorers, attached signs, etc.

^** Business Personal Property should include computers, furniture, fixtures, etc.

Crime

Employee Dishonesty Coverage - $500 deductible (check desired limit):

$10,000

$25,000

$50,000

Theft, Disappearance and Destruction ? Inside and Outside - $500 deductible (check desired limit)

$1,000

$2,500

$5,000

$10,000

Number of employees who handle or have custody of money:

Auto

Any autos owned by the bowling center? Yes No

Year, make & model Vehicle ID# Comp. Deductible Coll. Deductible Cost New

Umbrella

Excess Liability coverage desired? Yes No

Limit: $1,000,000 $2,000,000

Child Care

Do you provide child care for bowlers? Yes No

Loss History

List all losses for the current year and past three years: (Property - i.e.: fire, smoke, theft, wind, hail, water damage, etc.; General Liability - i.e.: slip & fall, lawsuits, etc.)

Date of Occurence Description Amount Paid Amount Reserved Open or Closed

Describe any losses over $10,000:

Warranty

I hereby certify that all the above statements are true and correct to the best of my knowledge.