GAMING INSURANCE QUESTIONNAIRE
GENERAL INFORMATION
1. Name of Insured (Applicant):2. What is the insured’s FEIN number?
3. What is the insured’s website address?
4. Number of years in business?
UNDERWRITING INFORMATION
5. Kind of operation: Casino Off Track Betting Parlor Card Club Bingo Hall Other
6. Does any named insured not share 51% common ownership with the first named insured? Yes No
7. Is the proposed insured a subsidiary of another company? Yes No
If yes, name of parent company:
8. Annual Liquor ReceiptsAnnual Payroll of Gaming OperationsNo. of Employees
9. Date gaming facility was constructed:
Construction: Joisted Masonry Frame Fire Resistive
Non-Combustible Mixed Other Describe:
Date of any major reconstruction:
Does gaming facility contain a theatre or live show area? Yes No
Does the building have sprinklers? Yes No
10 Does the insured have central station alarms? Yes No
If yes, distance to the nearest fire station?
11. Are any construction projects planned for the coming year? Yes No
(Construction means: new buildings, additions, added walls/ceilings/floorsand demolition)
If yes, explain:
12. Has an emergency/contingency plan been promulgated for the facility? Yes No
If so, please include a copy of your emergency evacuation plan.
13. Does the insured have contracted employees? Yes No
If yes, who provides WC?
14. Does sovereign immunity apply? Yes No
15. Do you have fireworks? Yes No
Is a licensed and insured pyrotechnician used that lists the facility as an additional insured? Yes No
16. Is a log kept of inspections completed and maintenance performed throughout the facility? Yes No
17. Are tables and chairs in good condition and subject to regular inspection and repair? Yes No
18.Number of years current management has operated this gaming facility:
19. Medical Services
Do you have employees trained in First Aid? Yes No
20. Patron Services
Are any shuttle services provided for patrons? Yes No
If yes, are shuttle drivers required to carry a CDL? Yes No
If off-premises, distance traveled?
Are MVR's obtained annually for shuttle drivers? Yes No
Are curbs, steps and ledges highlighted? Yes No
Are stairways and emergency exit routes equipped with emergency lighting? Yes No
21. Parking
Do you provide valet parking? Yes No
Are MVRs obtained annually? Yes No
Are criminal background checks conducted? Yes No
Do you have a key control system? Yes No
Are vehicles ever driven across a public road? Yes No
Does security monitor parking areas? Yes No
22. Hotel
Is there a hotel on the premises? Yes NoIf yes, please complete HOTELS SUPPLEMENT form.
A.EMPLOYEE BENEFITS LIABILITY
(Please complete this section if you need a quote for Employee Benefits Liability Coverage. If you do not need a quote for Employee Benefits Liability, please skip this section and continue to the next section.)
23. Is there a designated person or department that handles employee benefits enrollment? Yes No24. Number of employees under employee benefit program administered in the U.S. or Canada:
25. On optional enrollment items, is a signed acceptance/rejection page collected? Yes No
If yes, is the signed acceptance or rejection retained in the employee's personnel file? Yes No
26. Are all benefits available to all employees? Yes No
27. Has any error and omission loss ever been sustained or is any such claim pending? Yes No
B.LIQUOR LIABILITY
28. Is liquor handled by: Insured Subcontractor29. Do you stop serving at least one hour prior to closing? Yes No
30. Name on liquor license: / Liquor license number:
31. Has applicant's liquor license ever been revoked or suspended? Yes No
If yes, please explain:
32. Has applicant ever been fined by alcoholic beverage control or other governmental regulator? Yes No
If yes, please explain:
33. Are patrons allowed to carry alcoholic beverages onto the premises? Yes No
If yes, what type?
34. Do you exercise the right of search and seizure of contraband items? Yes No
If yes, how do you notify the public of this?
35. Do all servers receive alcohol awareness training? Yes No
Name of training program:
36. Are rules and regulations clearly displayed for patrons viewing? Yes No
37. Is there a limit placed on the quantity of alcoholic beverages purchased at one time? Yes No
38. Is the parking area patrolled to prevent intoxicated drivers from leaving the premises? Yes No
39. Is there any type of designated driver program? Yes No
C.SECURITY COVERAGE
40. Are security cameras on site? Yes NoPercentage of area covered.
Is there a formal process of locating, retrieving and security tape in case of incident? Yes No
How long are video tapes kept?
41. Do any security personnel carry a firearm as part of their equipment while on duty? Yes No
If yes, number of armed security personnel:
What training and licenses are required?
D.RESTAURANT/FOOD SERVICE OPERATIONS
42. Are all cooking surfaces protected by automatic fire extinguishing systems? Yes No43. Are automatic fire extinguishing systems serviced by outside contractor? Yes No
44. Are hoods/duct work cleaned by outside service contractor? Yes No
Please provide the following with this application:
ACORD applications
Loss runs
- Five years currently valued
- Details of losses greater than $25,000
Current audited financials
Description of named insureds
Subcontractor agreements
- Copies of certificates of insurance
Schedule of special events/activities
Emergency Response Plan (at least index page)
Lease agreement (if applicable)
I hereby represent and confirm that I have read all of the questions and answers contained herein and that, to the best of my knowledge, the information is true and correct.
I further acknowledge that I understand that this information is provided in conjunction with and in addition to the ACORD application(s) referenced above and that the information contained herein is subject to the same notices, disclaimers, warranties, and representations as on the referenced application(s).
DateSignature of Insured or Authorized RepresentativeTitle
Send completed form along with referenced ACORD application(s) to:
American Specialty Insurance & Risk Services, Inc.
7609 W. Jefferson Blvd.
Suite 100
Fort Wayne, IN 46804
Phone:(800) 245-2744
E-mail:
Form No. AMSP GAMING.QUESTIONNAIRE (05/17) Page 1 of 3SP # 7471030
American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and A S Insurance & Risk Services Agency. All rights reserved.