Archery Retailer Insurance Application
Personal Information 
Name of Business
Mailing Address
Location Address
City  
State
Zip
Phone
Contact Person
Email
 
Current Insurance Company, Expiration Dates & Premiums
Property:
Liability:
Auto:
Umbrella:
Approximate Annual Sales:
Archery:    
Firearms:    
Types of firearms:
Years in Business:
Have there been 3 or more covered losses and/or has any single loss exceeded $5,000?
No Yes
Building Specifications:
Building Limit:
Inventory Limit:
Deductible Options: $250 $500 $1,000
Construction of Building:  Age: 

Square Footage: Sole Occupant: No Yes
Other Occupancies? No Yes
Within City Limits?

No

 Yes
Alarm System?

No

 Yes
100% Sprinkled? No Yes
Distance to nearest fire hydrant?  
Have there been any physical improvements or updates on the building? No Yes
Date of improvement:
Are sidewalks and parking lots in good condition?

No

Yes
Commercial General Liability Specifications:
Limits included:
$2,000,000  General Aggregate (except Products-Completed Operations)
$2,000,000  Products-Completed Operations Aggregated
$1,000,000  Personal and Advertising Injury
$1,000,000  Each Occurrence
$300,000  Fire Damage (any one fire)
$5,000  Medical Payments (any one person)

Commercial Automobile Specifications:
Make Model & Year VIN
Full Coverage for each vehicle? No Yes
Deductibles: Comp: Coll:

Primary Driver of each vehicle, drivers license #, and date of birth:
Name on Title of each vehicle:
Other information you wish to provide:
Range Locations:  
Indoor range:
Outdoor range:
Field range:
Number of Lanes:
Range Dimensions:
Total Range:
Maximum distance shot:
Distance behind shooting lanes:
Space between shooters:
Is your range in compliance with any recognized standards (i.e. AAC, NFAA, etc.)? No Yes
Information on shooters:
Any age restrictions? No Yes
Any league or competitive shooting? No Yes
Accommodations for handicapped? No Yes
Do you allow broad heads to be shot? No Yes
Are spectators allowed?
No Yes If, so describe seating arrangements?

Can people get in behind the target butts or retrieve pass-through shots?

No

 Yes

If yes what controls are in place to make sure shooting does not resume until all shooters return to the firing lane?
Please explain:

Any exit doors down by the target?

No

 Yes

If so, how is it controlled so that people are not entering during a shoot? Please explain:

Range supervision:

Is a supervisor on duty at all times?

 No

Yes

Is the range visible from the retail section?

 No Yes

Is it segregated from the retail section?

 No Yes

Do you have written rules?

 No Yes

Are these rules prominently displayed?

 No Yes

Are rules discussed with shooters before they shoot?

 No Yes

Do you give lessons?

No

 Yes

If so, what are the qualifications of the instructors?

Do you provide loaner or rental bows?

No

 Yes

If so, do the bows leave the premise?

Do you repair or manufacture any products?

No

 Yes

If so, please describe the items.