Named Insured
*
Applicant's Name
*
Organization Type
Street Address
*
City
*
State
*
Zip
*
Phone
*
Fax
Email
*
General Liability Limit requested
Excess Liability
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
Opening Date
*
MM
DD
YYYY
Closing Date
*
MM
DD
YYYY
Estimated number of patrons for entire period
Estimated gross receipts for entire period
Attraction is
How many years has this event been held before?
How many stories tall is the attraction?
*
Are all entrances, exits, and/or steps adequately lit?
Are all stairs and/or steps adequately equipped with handrails?
Are there any ramps, slides, trap doors, or moving floors?
*
If Yes, please explain in detail
Will live actors be used in the attraction?
Will any actors be in any type of contact with patrons?
*
If Yes, please explain in detail
Will children under 6 years of age be required to be accompanied by an adult?
Will any animal(s), reptile(s), or hangman's noose(s) be used?
Will any moonwalks or similar devices be used?
Fraud Statement
*
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 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.
Warranty Statement
*
I hereby warrant and confirm that the above information, to the best of my knowledge, is true and correct, and further certify that I have read all of the questions and answers on this application. I understand this application is a requirement for coverage, a part of the contract and evidence of my acceptance of this insurance, and any falsification or misrepresentation will be deemed a breach of contract, voiding all insurance coverage. It is understood and agreed that the completion of this application shall not be binding either to the proposed insured or the company until accepted by the company or companies in writing.
Title
Name of Applicant
*
Signature of Applicant
*
Date
*
Name of Authorized Agent or Broker
Name of Agency
Agency Mailing Address
Email
Phone
Fax
Checkbox 3
No Mechanical Devices or Machinery with Moving Parts
No Chutes, Slides, Trap Doors, Movable or Sharply Inclined Floors
No Use of Live Animals
No Physical Contact to Patrons by Actors
Warnings Posted for Pregnant Women and/or Those with Heart Conditions
No Open Flames
All Steps to be well Lighted and Include Handrails
Adequate Emergency Lighting
Exits Well Marked
Buildings Must Meet or Exceed Local Zoning and Fire Codes
Hayrides Must Be Tractor Drawn — No Horse Drawn Hayrides
Hayrides Must Be On Private Property — No Public Roads
Title
Name of Applicant
*
Signature of Applicant
*
Date
*
