Basic Information
Type: Individual Broker Names Insured: DBA's: Loss Control Contact Name: Phone: Website: Fax: Email: Quote Needed By:
Physical Address:
Address: City: State: Zip:
Mailing Address:
Same as Physical Address
Address: City: State: Zip:
Do you operate out of any other locations (addresses)?
Yes No 1: 2: 3:
Type of Entity:
Corporation IndivIDual Partnership Joint Venture LLC
FEIN:
Date business started under current ownership
If less than 5 years, please respond to the following questions:
a. Have you worked elsewhere in a similar business? yes no If Yes, how many years? b. Does your staff have prior experience? yes no If Yes, how many years? c. Do you work with inflatable consultants? yes no If Yes, how many years? Policy Expiration Date:
Proposed Effective Date:
Any policy or coverage declined, cancelled or non-renewed during the prior 3 years
yes no
Expiring Premium:
Plus 3 Premium Years:
Present Coverage
General Liability Umbrella/Excess Property Name of Carier Limits of Carrier Deductible Policy Term Retroactive Date Premium
CLAIM HISTORY 3-5 YEAR CURRENT LOSS HISTORY – REQUIRED TO OBTAIN VALID QUOTE
General Inforamtion
Rental Operations - Business which primarily rents amusement devices and related equipment. Inflatable Fun Facilities Party Rental Stores operate any other businesses
Deductable: $2,500 $5,000 $25,000
Equipment Schedule(Required for General Liability and Inland Marine Quotes) - Item Serial Number Replacement Value Age
1. Miscellaneous Rentals and Supplies – Rents the machine and sells the supplies for airbrush tattoos, face paint booth, fog / smoke / bubble / foam machines, casino games, Karaoke machine, portable generators (for use with inflatable and mechanical devices), etc. including arcade games and TV Show games. 2. Simple Mechanicals – Rents simple mechanical rides such as merry go rounds, small ferris wheels, Hi-Stryker, Trackless Train, Trikes, Bumper Boat Kars, etc. 3. Simple Devices – Rents air filled amusements and devices such as advertising signs, bouncing / jumping units (primarily designed for small children), Bouncer, Bowling, LaserTag. 4. Interactive Devices – Rents devices where there is direct interaction between participants such as paint ball, dunk tanks, mini golf driving ranges (potential to hit other participants), putting greens (potential to hit other participants), and other devices including auto belay rock walls. Rents mechanical bulls or auto rock walls. 5. Batting Cage, GoKarts, Haunted Attractions, Mechanical Bull, Slides, Velcro Wall, H2O Equipment. 6. Bungee Run, Sumo Suits, Boxing, Joust, Manual Belay Rockwall. 7. Entertainers / Performers – Supplies clowns, costumed characters, DJ (disc jockey), and magicians. Are they Subcontracted Employees b. Are background checks done? Yes No c. If subcontracted, do you get copies of their certificates with limits equal to yours? Yes No 8. Food and Beverage Products and Rentals – Rents the machine and sells the supplies for cotton candy makers, hot dog steamers, popcorn machines, nacho machines, soda dispensers, slush makers, etc. 9. Tables, Tents, Chairs. 10. Restaraunts, Snack Bars 11. Catering Total
Risk Assessment - Provide details to any "Yes" answers.
1. Do you have an employee and customer operator safety program? Yes No 1a. Do customers sign documentation after said program? Yes No 1b. Do employees sign documentation after said program? Yes No
2. Do you provide written operating instructions for scheduled equipment? Yes No
3. Do you utilize an inspection sheet for inflatable and mechanical amusement rides? Yes No
4. Is there a formal ride/equipment maintenance program including maintenance logs? Yes No
5. Is equipment stored inside? Yes No
6. Is your yard secured? Yes No
Describe:
7. Do you have any formal safety training such as SIOTO, ROAR, AIMS, Red Cross, NAARSO, IALEI, or Commonwealth of PA? Yes No
Risk Management - Provide details to any "Yes" answers.
1. Is there a written rental agreement between you and your client? Yes No
2. Percentage of time your rental agreement was used without alteration?
3. Percentage of time a customer provided contract is used: Percentage of customers you do business with: Individuals: % Corporations and Schools: % Governmental: %
4. Total number of staff during the year: Number of Full-time Employees: Number of Part-time Employees: Number of Seasonal Employees:
Questions Regarding Equiptment Rental
1. Do you rent any of your amusement devices/rides without operators/attendants? Yes No If yes, what percentage is without operators? Do the amusement devices/rides have signs clearly marking age, height, or size limitations? Yes No
2. Is any equipment left over night at the site where it was used? Yes No
3. Do you use the manufacturer’s checklist for the set up and use of the equipment? Yes No
4. Do you utilize the Watchdog™ Siren Warning Device? Yes No What percentage of your inflatable rentals use a Watchdog™ Siren Warning device?   %
TYPES OF EQUIPMENT - Must provide current equipment list with Application to obtain valid quote.
ROCKWALL SUPPLEMENT
1. Is the rockwall supervised by a trained operator at all times? 2. Is the tool loop cut off from the safety harness? 3. When the rockwall is not in use, how and where do you store it? 4. How often are the cables replaced? 5. Is the rockwall manual or auto balay?
Current Carrier
Effective Date of Current Policy
If you would like a quote for Inland marine to provide coverage for incidental loss or damage, please complete the section below:
1. Is equipment stored inside? Yes No 2. Are buildings occupied or vacant? Occupied Vacant 3 Are buildings located in Flood Zone? Yes No 4. Any water damage to equipments in the past? Yes No If yes, explain. 5. Are buildings located in Wind Zones? Yes No 6. Any wind damages to equipment in the past? Yes No If yes, explain. 7. Are buildings located in Earthquake Zones? Yes No If yes, explain. 8. Construction of building Frame Brick Masonry 9. Smoke Alarm? Yes No 10. Central Alarm? Yes No 11. Fire extinguishers on premises? Yes No   14. How are equipments transported? You deliver? Yes No Customers pick up? Yes No By common carriers? Yes No 15. Formal safety and maintenance programs in place? Yes No 16. Do you keep original receipts of equipments purchased? Yes No 17. Do you require the renters to sign a contract to indemnify you for damages to rental equipment? Yes No 18. How many pieces of your equipment are over: 10 years old: How many pieces of your equipment are over: 20 years old:
FRAUD WARNINGS NOTICE TO ARKANSAS APPLICANTS: “ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.” NOTICE TO COLORADO APPLICANTS: “IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES DENIAL OF INSURANCE, AND CIVIL DAMAGES, ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES.” NOTICE TO DISTRICT OF COLUMBIA APPLICATIONS: “WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.” NOTICE TO FLORIDA APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY IN THE THIRD DEGREE.” NOTICE TO KENTUCKY APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.” NOTICE TO LOUISIANA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.” NOTICE TO MAINE APPLICANTS: “IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.” NOTICE TO MINNESOTA APPLICANTS: “A PERSON WHO SUBMITS AN APPLICATION OR FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME.” NOTICE TO NEW JERSEY APPLICANTS: “ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.” NOTICE TO NEW YORK APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.” NOTICE TO OHIO APPLICANTS: “ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.” NOTICE TO OKLAHOMA APPLICANTS: “WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY” (365:15-1-1036 3613.1) NOTICE TO PENNSYLVANIA APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.” NOTICE TO VIRGINIA APPLICANTS: “IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY, PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.” SIGNING OR SUBMISSION OF THIS APPLICATION DOES NOT BIND THE UNDERSIGNED TO PURCHASE ANY INSURANCE, NOR DOES IT IN ANY WAY SIGNIFY ANY ACCEPTANCE OF ANY COVERAGE ON THE PART OF THE COMPANY. THE APPLICANT IS HEREBY APPLYING TO THE COMPANY FOR A POLICY OF INSURANCE AS SET FORTH IN THIS QUESTIONNAIRE ON THE BASIS OF THE STATEMENTS CONTAINED HEREIN.

Click here to save and continue later. When completely finished please click "SUBMIT" at the bottom of he page.