General Liability Insurance Applications and Questionnaires

Broker Name
Broker Phone
Broker Email
Broker Address

Airbrush - Temporary Tattooist

Desired Effective Date:

Liability Limit Desired: (choose one)
$100,000 $300,000 $1,000,000
General Liability is included within the PL limits selected.

Do you want optional business equipment limits?  Yes  No
(Please fill out the Business Equipment Schedule)

Previous Insurance Company:

Have you had any losses in the last four years?  Yes  No
If yes, please provide details:

Select professional service(s) that you are certified to perform:
Airbrush Tattoo - Do you use any Henna ink?  Yes  No
Airbrush Training

Do you lease/rent booth space?  Yes  No

Do you provide services at your client's choice of location?  Yes  No

If you provide any other services or operations than those listed above - Explain:

Do you want blanket additional insured coverage for up to six additional insureds?  Yes  No

Loss Payees to be added to your policy (Only applicable with equipment coverage).

Name:

Address:

City: State: Zip:

Interest:

Do you obtain Hold Harmless Agreements and Parental Consent Forms as required by the state in which you are providing services?  Yes  No

Business Equipment Schedule
Complete this schedule if you require coverage for your business equipment
Year Manufactured	Equipment	Itemized Value
	Total of Misc items valued less than $100 each
	Total Value of Equipment

Business and Insurance Information

Current Insurer

Current Limits of Coverage

Proposed Effective Date

Current Premium

Is this policy being non-renewed?  Yes  No

     If yes, please explain:

Insurance claims against you in the past 5 Years?  Yes  No

If yes, please list:

Date of Claim	Description of Claim	Open/Closed	Paid $	Reserve $
		SelectOpenClosed
		SelectOpenClosed
		SelectOpenClosed
		SelectOpenClosed

Your Annual Gross Revenues from Planning Events is $

*Total number of events per year:

*Is this a Full or Part time occupation?  Full Time  Part Time

Describe the types of events you organize.

Which category would then best describe the nature of your business?

Social Events (Wedding, Bar/Bat Mitzvah, Anniversary, Birthday, etc.)   Maximum Budget per Event $

Corporate Events (Charities, festivals, trade shows, conventions, etc.)   Maximum Budget per Event $

Other Events – please clarify here:   Maximum Budget per Event $

Limits of Liability

General Liability Limits (select one)
$1,000,000 Per Occurrence / $2,000,000 Aggregate
$1,000,000 Per Occurrence / $1,000,000 Aggregate
$500,000 Per Occurrence / $500,000 Aggregate

Professional Liability Limits (select one)
$1,000,000 Per Occurrence / $2,000,000 Aggregate
$1,000,000 Per Occurrence / $1,000,000 Aggregate
$500,000 Per Occurrence / $500,000 Aggregate

Stop Gap Liability Limit (select one)
N/A
$1,000,000 Per Occurrence / $1,000,000 Aggregate
$500,000 Per Occurrence / $500,000 Aggregate

Risk Assessment Questions

*Contracts - Do you have a contract with all of your clients?  Yes  No

If “Yes,” please submit a copy.

*Subcontractors - Do you use subcontractors on any events you plan?  Yes  No

If “Yes,” do you require that you/the business be listed as an additional insured on their insurance?  Yes  No

*What limits of liability do you require your subcontractor to carry? $

*Do you obtain a certificate or proof of insurance from all your subcontractors?  Yes  No

If No, please explain.

Please provide details to any “Yes” answers below.	Yes	No
*1. Do you have any other insurance?
*2. Any insurance declined, cancelled or non-renewed in the past 3 years (N/A in MO)
*3. Any operations sold, acquired or discontinued in the last 5 years?
*4. Have you been or are you active in any joint ventures or other corporations?
*5. Any past losses or claims relating to sexual abuse/molestation allegations?
*6. Any past losses or claims relating to discrimination or negligent hiring allegations?
*7. Do you have any inflatable games, other games, rides or concessions?
*8. Do you have a formal safety program?
*9. Any animal related exposures?
*10. Do any of your events include adult entertainment or adult themes?
*11. Do any of your events provide any gambling entertainment?
*12. Do you organize any sporting events?
*13. Do you use any fireworks or pyrotechnics in your events?
*14. Do you organize any stunts or other special effects?
*15. Any crimes, attempted or successful, on your premises in the last 5 years?
*16. Any exposure to radioactive or nuclear materials?
*Explanations to “Yes” answers

Optional - Inland Marine/Mobile Property Insurance (a $500 Deductable applies)

If you want a quote for incidental loss or damage, list your equipment below or attach a separate schedule.
Equipment Description	Cost of the Equipment	Serial Number (if applicable)
	$
	$
	$
	$
	$
	$

REQUESTED INSURANCE LIABILITY LIMITS:

	Option #1	$1,000,000 Occurrence	$1,000,000 General Aggregate
	Option #2	$1,000,000 Occurrence	$2,000,000 General Aggregate
	Option #3 - Other

COMPANY BACKGROUND INFORMATION:

Date business started under current ownership:

Education/Employment Experience (Please briefly describe your educational and employment history):

Briefly describe your business operations that the insured equipment will be used in:

Gross Revenue (last 12 months): $

Gross Revenue (next 12 months): $

Total number of staff during the year:

Full Time Employees:

Part Time Employees:

Seasonal Employees:

Minimum Age of Employees/Attendants:

Are employees leased to or from other employers?  Yes  No

If yes, please explain:

Do you subcontract any work?  Yes  No

If so, what?

Do you require all subcontractors to provide you with a certificate of insurance?  Yes  No

Do you require all subcontractors to name you as an additional insured?  Yes  No

What limits of liability do you require of the subcontractor(s)? $

If no specific limits are required, explain practice:

Do you lease equipment to others with or without operators?  Yes  No

If Yes, please explain:

RISK ASSESSMENT:

	Yes	No
1. Do you have a formal written safety program?
2. Is there a written rental agreement between you and your client?
Please attach:
3. Is there a written liability waiver agreement between you and your client?
Please attach:
4. Percentage of time your rental agreement was used without alteration	%
5. Percentage of time a customer contract is used	%
6. Percentage of customers you do business with
Individuals: %     Corporations and Schools %     Governmental %
7. Do you have written Customer Training procedures?
8. Do you have written Equipment Maintenance procedures?
9. Do you have written Employee Training procedures?
10. Does your website or brochures make statements that warranty or guarantee the safety of your equipment?
11. Are there any animal related exposures?

INSURANCE INFORMATION:

Section A

Did you previously have liability insurance on the equipment that you are requesting a quote on?

No If you answered "NO" to the previous question, you are representing that you have NOT had liability insurance AND that you are NOT aware of any claims on the equipment you are currently seeking liability coverage for.


Yes If you answered "YES" to the previous question, please proceed to Section B below:

Section B

Current Carrier & Limits of Liability:

Amount of Expiring Premium:$

Have you had any liability policy non-renewed/cancelled in the last 5 years?  Yes  No

Have you any claims and/or losses on the equipment that you are currently seeking liability coverage for?  Yes  No

If you answered "YES" to the previous question, please complete the following:

Date of Claim	Description of Claim	Open/Closed	Paid $	Reserve $
		SelectOpenClosed
		SelectOpenClosed
		SelectOpenClosed
		SelectOpenClosed

Are you able to provide EPA Management & Insurance Solutions, Inc. with a copy of your loss history from your previous insurer?

 Yes  No

If you answered "NO" to the previous question please state in detail why you are unable to provide loss history information to EPA Management & Insurance Solutions, Inc.:

EQUIPMENT SCHEDULE:

Indicate quantity for all applicable equipment owned or operated. Please note that there is no coverage for any equipment not indicated.

’ ’ ’ ’ ’

INFLATABLES/GAMES	Quantity
Bouncers / Moonwalks (Must Have 4 Sides)
Combos - Dry
Combos - Wet
Obstacle Courses
Ball Pit
Balloon Typhoon
Bungee Basketball
Bungee Run - One on One
Gladiator Joust
Human Bowling
Human Foosball
Inflatable boxing Ring w/ Oversize Non-Inflatable Gloves/ Mondo Boxing
Inflatable Caterpillar Climb-thru
Inflatable Horse Bounce / Pony Hoppers
Inflatable Maze
Inflatable Space Mountain
Inflatable Twister
BUNGEE TRAMPOLINE
Single
Double
Quad
SLIDES - (Measure from platform height not top of unit.)
Inflatable Slide - NO WATER 0-14'
Inflatable Slide - NO WATER 14'.1"–24'
Inflatable Slide - WATER 0-14'
Inflatable Slide - WATER 14'.1"-24'
Slip N Slide Water Fun
CLIMBING WALLS
Rock Climbing Wall - Permanent - Please Complete Supplement
Rock Climbing Wall - Portable/Inflatable - Please Complete Supplement
Rock Climbing Wall with Monkey Motion Jumper
MECHANICAL BULLS
Mechanical Bull - Please Complete Supplement
GAMES
Bingo Game / Raffle Drum
Carnival Games (small) / Interactive Games of Chance
Dunk Tank (Check: Plastic Metal)
Games - Small Tabletop
Giant Operation Game
Golf Simulator
Hi Striker
Jacob's Ladder
Laser Tag
Power Shower or Pitch Burst
Rodeo Roper (Horse & Calf STATIC Display)
Tricycle Car Wash Race
Twin & Spin
Velcro Wall
Video Games or Pin Ball Machine
Water Balloon Wars
Wheel of Fortune or Spin for Prize Equipment
ENTERTAINMENT
Air Brush Tattoo
Balloon Artist
Bubble Machine
Clown
Costume Characters
Theme Party with Costume Character - Indoor
Theme Party with Costume Character - Outdoor
Dance, Dance Revolution
Disc Jockey - Please Complete Supplement
Face Painting
Foam Dance Pit
Fog Machine / Smoke Machine
Game Show Host including set and lighting
Interactive Light Show
Karaoke Equipment / Recording Studio Box
Money Machine / Cash Cube - Inflatable
Money Machine / Cash Cube - Permanent
Movie Screen - Aluminum 12x12 Feet
Movie Screen - Inflatable 6x8 Feet
Movie Screen - Inflatable 12x16 Feet
Movie Screen - Inflatable 18x 24 Feet and Larger
Photo Booth Machine
Spin Art Machine or Sand Art Machine
Wax Hands - Art Form Studio
SPORTS
Airborne Adventure
Baseball Radar Pitch
Batting Cage
Burn Out Mini Drag Strip - NOT RIDING
Mechanical Surf Board
Mini Golf Driving Range - Portable
Mini Golf Driving Range - Permanent
NASCAR Mini Race Track - NOT RIDING
Portable Scoreboard
Ropes Courses
Ski / Surf Simulator
Sports Games: Foosball, Basketball 'Hoops' Toss, Horseshoe, etc.
Sumo Wrestling - Inflatable Mattress Only, NO FOAM
RIDES
Berry Ride (Strawberry)
Ferris Wheel - Mini (only 18 feet and under in height)
Gyroscope / Orbotron - Seated
Gyroscope / Orbotron - Standing
Human Sphere
Merry-Go-Round - Child Only (Less than 10 horses)
Mini Train - Trackless with Driver
Mini Train - with Track and Attendant
Helicopter
Turbo Swing
Turbo Tubs
CONCESSIONS
Chairs
Tables
Cotton Candy Machine
Gas Grill
Hot Dog Steamer
Nacho Machine
Peanut Roaster
Popcorn Machine
Shaved Ice Machine
Snow Cone Machine
Tents/Canvas Goods - 10' x 10'
Tents/Canvas Goods - 10' x 15'
Tents/Canvas Goods - 20' x 20'
Tents/Canvas Goods - other size
MISCELLANEOUS
Cold Air Inflatable Advertising Sign & Nylon Sky Dancer - Under 6 Feet
Cold Air Inflatable Advertising Sign & Nylon Sky Dancer - 6 to 15 Feet
Costume Characters
Generators
Playground (Not Inflatable) - 6 Feet with Ground Cover
Trailer - Gooseneck
Other

QUESTIONS IN REGARDS TO ABOVE EQUIPMENT:

	Yes	No
Do you have any equipment that you have not identified above and that you DO NOT want covered by this insurance policy? Please explain:
Do you allow customer pick-up of equipment - Inflatables, Bouncers/Slides/Rides?
Do you allow customer pick-up of Concession Equipment?
Do the amusement devices/rides have signs clearly marking age, height, or size limitations?
Do you use independent contractors to deliver and set up the equipment?
Do you or your employees always supervise the rental of equipment while it is in use?
Do you use the manufacturer's checklist for the set up and use of equipment?
Do you utilize the Watchdog Siren Warning Device? If so, how many devices do you have?

Revenue Breakdown

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. 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 relay rockwall	$
7. Entertainers / Performers - Supplies clowns, costumed characters, DJ (disc jockey), and magicians.	$
a. 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. Restaurants, Snack Bars	$
11. Catering	$

Mechanical Bull Supplemental Information

Please complete only if applicable

GENERAL INFORMATION:

Estimated Annual Receipts from the following:

All Operations $

Portable/Temporary Location Bulls $

Stationary/Permanent Location Bulls $

Other $

Other $

Name or Other Identity of Mechanical Bull	Age of Unit	Name of Manufacturer	Dimensions (LxWxH)	Portable (P) or Stationary (S)	Purchased New? (Y/N)	# of Days Used Annually
				SelectPortableStationary	SelectYN
				SelectPortableStationary	SelectYN
				SelectPortableStationary	SelectYN
				SelectPortableStationary	SelectYN

FOR PORTABLE/TEMPORARY LOCATION MECHANICAL BULLS ONLY:

Describe fall protection characteristics of your portable Mechanical Bulls:

What is the maximum number of people permitted on any one bull at a time?

Is there a minimum age for participants?  Yes  No

If so, what is it?

Do you require participants to sign a release of liability and/or waiver?  Yes  No

If so, please attach a copy of such waivers/releases of liability.

Please describe your emergency response plan in case of an accident:

FOR STATIONARY/PERMANENT LOCATION BULLS ONLY:

Where is your Mechanical Bull located?

Please provide brochures or other materials describing the facility where the Bull is located.

Is alcohol sold at the facility where the Mechanical Bull is operated?  Yes  No

Were all of your mechanical bulls constructed by manufacturers who provided you with Certificates of Insurance (COI) which includes products and completed operations coverage?  Yes  No

Describe fall protection characteristics of your stationary Mechanical Bulls:

What is the maximum number of people permitted on any one bull at a time?

Is there a minimum age for participants?  Yes  No

If so, what is it?

Do you require participants to sign a release of liability and/or waiver?  Yes  No

If so, please attach a copy of such waivers/releases of liability.

Is your stationary Mechanical Bull limited to on-premises use only?  Yes  No

If so, please explain?

Please describe your emergency response plan in case of an accident, including distance of your facility from ambulance and hospital:

Climbing Wall Supplemental Application

Please Complete Only if Applicable

GENERAL INFORMATION:

Estimated Annual Receipts from the following:

All Operations $

Portable Walls $

Stationary Walls $

Other $

Other $

Describe your procedures and requirements for climbing wall safety training for all employees:

Name or Other Identity of Climbing Wall	Age of Wall	Name of Manufacturer	Height	Auto Belay (Y/N)	Portable (P) or Stationary (S)	Purchased New? (Y/N)	# of Days Used Annually
				SelectYN	SelectPortableStationary	SelectYN
				SelectYN	SelectPortableStationary	SelectYN
				SelectYN	SelectPortableStationary	SelectYN
				SelectYN	SelectPortableStationary	SelectYN

FOR PORTABLE CLIMBING WALLS ONLY:

Describe fall protection characteristics of your portable climbing walls:

Are any of your walls inflatable or air pressurized (as opposed to rigid-wall)?  Yes  No

If so, please explain

What is the maximum number of people permitted on any one wall at a time?

Is there a minimum age for participants?  Yes  No

If so, what is it?

Do you require participants to sign a release of liability and/or waiver?  Yes  No

If so, please attach a copy of such waivers/releases of liability.

FOR STATIONARY CLIMBING WALL FACILITIES ONLY:

Describe fall protection characteristics of your stationary climbing walls:

Are any of your walls inflatable or air pressurized (as opposed to rigid-wall)?  Yes  No

If so, please explain:

What is the maximum number of people permitted on any one wall at a time?

Is there a minimum age for participants?  Yes  No

If so, what is it?

Do you require participants to sign a release of liability and/or waiver?  Yes  No

If so, please attach a copy of such waivers/releases of liability.

What percentage of use is from membership/members of facility? %

Do you have a pro shop?  Yes  No

If yes, please provide gross receipts: $

Do you rent equipment?  Yes  No

If yes, please provide full details:

Is equipment rental limited to on-premises only?  Yes  No

If not, please explain:

Please describe your emergency response plan in case of an accident, including distance of your facility from ambulance and hospital:

Do you arrange/sponsor any off-site travel or excursions?  Yes  No

If so, please provide details of those operations including # of people involved for each trip.

DJ General Liability & Equipment Application

Please Complete Only if Applicable

Description of operations: If DJ - # of Systems Owned? # of DJ's Employed? # of Jobs Per Yr.?

Types of Functions:

What percentage of your music at any one event is rap and/or hip hop? %

Do you rent any additional equipment beyond the scope of music amplification (i.e. dance floors)?  Yes  No

If Yes, please explain:

Please submit completed and signed application to us along with the following consideration:

• Include updated loss runs from previous insurance companies
• Include copies of any printed material such as brochures and other marketing materials
• Provide resume/biography of principal(s) if ownership is less than 2 years

LIMITS OF LIABILITY REQUESTED	PREMIUMS
General Aggregate $	Premises/Operations $
Products & Completed Operations Aggregate $	Products/Completed Operations $
Personal & Advertising Injury $	Other $
Each Occurrence $	Total $
Fire Damage (any one fire) $
Medical Expense (any one person) $
Other Coverages, Restrictions, and/or Endorsements Deductible $

Description of operations:

Payroll:

Food Receipts:

Liquor Receipts:

Misc. Receipts:

Please provide percentage breakdown in the following categories:

Parties %     Wedding %     Airline Industry %

Meetings %     Conventions %     Sporting Events %

1. Does applicant have liquor liability?  Yes  No
   If yes, please indicate:
   Carrier:
   
   Limits:
2. Does applicant own or lease (long term) a hall?  Yes  No
   If yes, what is square footage?
3. Is there a parking area?  Yes  No
   If yes, is parking area lit?  Yes  No
4. Does applicant provide valet parking service?  Yes  No
   If yes, who is the Garage Liability Coverage carrier
5. Does applicant hire security guards?  Yes  No
   If yes, does applicant obtain certificate of insurance or is applicant named as an additional insured?  Yes  No
6. Total number of employees:
7. Does applicant have Workers’ Compensation coverage in force?  Yes  No
8. Does applicant lease employees?  Yes  No
9. Does applicant operate a limousine service for guests?  Yes  No
   If yes, who provides automobile liability coverage?
10. Where is food prepared: Commercial Kitchen Other
    If other, please provide complete details:
    
11. Does applicant package and sell food under you own label?  Yes  No
12. Are health department regulations followed?  Yes  No
13. How are dishes and linens cleaned and sanitized?
14. Describe food storage procedures:
    
15. Are records kept on food suppliers?  Yes  No
16. Equipment - Please note any of the following equipment used:
    Tents Folding chairs/tables Amusement Devices Space Heaters Barricades
    Tiki torches/live flame Portable Restrooms Dance Floors Grills (electric, gas, LPG)
17. Does applicant separately rent equipment to others  Yes  No
    If yes, what are receipts?
18. During the past three years has any company ever canceled, declined, or refused similar insurance to the applicant?  Yes  No
    If yes, please explain (not applicable to Missouri applicants):
    

Previous Insurer-Indicate premium and losses for the past three years. Describe all losses:

Year	Company	Pol.#	Premium	Losses Paid	Losses Reserved	Description

SCHEDULE OF HAZARDS
Loc. No.	Classification	Class Code	Premium Bases: (s) Gross Sales (p) Payroll (a) Area (c) Total Cost (t) Other	Terr.	Rate		Premium
					Prem/Ops.	Products/Comp. Ops.	Prem/ Ops.	Products/ Comp. Ops.

Stage name (if any):

Number of years in business:

Annual income earned as a performer/entertainer:

Describe your performance:

Does your performance involve any audience participation?  Yes  No
If yes, describe:

Where are your performances typically conducted?
Outdoor Venue Private Homes Indoor Stages Convention Centers
Other

Desired effective date:
Start my coverage on the day after my enrollment form and payment are received.
Start my coverage on this date:
Start my coverage upon my expiration date of:

Premium - Check One

Refer to Option I or Option II below for limits.

Rate	Option I $1,000,000	Option II $2,000,000
Per performer with an annual income of $30,000 or less
Per performer with an annual income between $30,0001 and $100,000

 

Liability Coverage and Limits Commercial general liability coverage protects the insured against liability claims for bodily injury and property damage arising out of premises, operations, products and completed operations. No deductible applies to liability claims.
Coverage	Limits - Option I	Limits - Option II
Commercial General Liability Each Occurrence	$1,000,000	$2,000,000
General Aggregate (other than Products-completed Operations)	$2,000,000	$2,000,000
Products-completed Operations Aggregate	$1,000,000	$2,000,000
Personal and Advertising Injury	Excluded	Excluded
Legal Liability to Participants	$1,000,000	$2,000,000
Medical Expenses (other than participants)	$5,000	$5,000
Damage to Premises Rented to You	$300,000	$300,000

Medical Payments For Participants Coverage

Medical Payments For Participants coverage pays the medical and dental expenses incurred by a participant when an accidental injury occurs while participating in your operations. The coverage is provided on a primary basis. A $0 deductible applies to each claim, and the benefit period is two years from the date of the accident. A participant is any person involved in audience participation or an interactive component of an insured performance or entertainment activity. Participants do not include the insured entertainer or performer.

Coverage		Limit
Medical Payments For Participants		$5,000 per claim

Notable Exclusions

The following exclusionary endorsements are part of the policy providing coverage for this program:

• Abuse or molestation
• Asbestos
• Designated operations exclusion - those activities listed as ineligible
• Designated operations exclusion - use of animals of fire
• Employment-related practices
• Amusement devices (rides, slides, inflatable, etc)
• Fireworks
• Fungi or bacteria
• Lead
• Personal and advertising injury
• Nuclear energy
• Pollution

Trade Show / Consumer Show Exhibitors Insurance Application

Converge will begin the day after the completed enrollment form and premium are received and approved by EPA, or on a later date you specify below. (If renewing coverage, please provide the expiration date of your current policy.

Start my coverage on this date:

Describe the type of product or service provided or being sold:

Select one of the following that best describe your business operations:

Food concessionaire or vendor		No. of food-selling locations or trailers:
Micro reality race tracks		No. of micro reality race tracks:
Trailer-non food, games or merchandise		No. of trailers:
Push carts or kiosks		No. of push carts/kiosks:
Home-based wedding vendor (this type of operation is available only for a single event coverage period)		Services being provided:
Performing group (this type of operation is available only for a single event coverage period)		Type of performing group:
Tent or outdoor vending area		Provide dimensions (sq. ft.):
Tradeshow exhibit or booth		Provide dimensions: (sq. ft.):

If applying for a single event coverage, please provide the following information:

Name of event:

Date(s) of event (include set-up and tear-down days: to

Hours of event: AM PM to AM PM

Location of event:

Venue name:

Street address:

City: State: Zip:

Equipment and Contents Coverage:

To avoid a co-insurance penalty, you must insure 100% of the replacement cost of your equipment and content for all of your locations.

Step 1. Fill in the values to determine your total replacement amount for ALL locations

Individually list any items with values over $5,000		Value
Provide values for categories below (DO NOT include those values already shown above)
Vendor inventory (such as items held for sale)
Supply inventory (such as equipment, giveaways, paper goods)
Trailer equipment, excluding products (such as trailers, signs, concession equipment, refrigerators, cooking equipment)
Portable storage units (not permanent structures)
Misc. equipment (please describe)
Total replacement value (add al lines above)

Step 2. List physical address where equipment and contents are stored (P.O. boxes cannot be accepted)

Location 1:

Street address:

City: State: Zip:

Location 2:

Street address:

City: State: Zip:

Complete this section to request additional certificates. Provide separate requests for each additional certificate needed.

This certificate is for our: Program coverage (commercial general liability) Equipment and content coverage

Type of certificate you are requesting: Additional insured Evidence of coverage Loss payee

Certificate holder information:

Entity name:

Street address:

City: State: Zip:

Relationship to named insured:
Owner/lessor of premises
Sponsor
Co-promoter
Mortgagee
Franchiser
Lessor of equipment and contents
Other

Special certificate language needed (please explain)

Date(s) of event/activity: to

Hours of event/activity: AM PM to AM PM

Type of event/activity:

Name of event/activity:

Location of event/activity:

Coverage and Limits
Commercial General Liability	Limits - Option I	Limits - Option II
Each Occurrence	$1,000,000	$2,000,000
General Aggregate (other than Products-completed Operations)	$3,000,000	$4,000,000
Products-completed Operations Aggregate	$1,000,000	$2,000,000
Personal and Advertising Injury	$1,000,000	$2,000,000
Damage to Premises Rented to You	$300,000	$300,000
Medical Expenses (other than participants)	$5,000	$5,000

Commercial General Liability - coverage which protects the insured against liability claims for bodily injury and property damage arising out of premises, operations, products and completed operations and personal and adverting injury.

Exclusions

The following exclusionary endorsements are part of the policy providing coverage for this program:

• Abuse or molestation
• Asbestos
• Designated operations exclusion - those activities listed as ineligible
• Designated operations exclusion - use of animals of fire
• Employment-related practices
• Amusement devices (rides, slides, inflatable, etc)
• Fireworks
• Fungi or bacteria
• Lead
• Personal and advertising injury
• Nuclear energy
• Pollution

Optional Coverage Available

This provides coverage for direct loss of damage to your vendor inventory, supply, trailers, equipment and portable storage units due to fire, theft, vandalism or other covered causes (subject to actual policy terms and conditions.) You must insure the full replacement cost of all your equipment and contents to avoid a co-insurance penalty at the time of loss. Should you add additional equipment or contents to your inventory, please contact EPA to have your insured value amended to avoid a co-insurance penalty.

Coverage conditions:

1. This coverage is not available in New Jersey.
2. Coverage is not available on stand-alone basis. You must have six month or annual commercial general liability coverage for your concessions, exhibitor or vendor business with EPA Concessionaires, Exhibitors & Vendors RPG Insurance Program.
3. Coverage cannot be extended to cover fine jewelry and fine art, non-structural glass and permanent structures such as concession stands or storage units that are not portable.
4. Coverage will be effective the day after we receive the proper completed enrollment form with premium and will expire one year from the effective date.

The Following Information is Required in Order for a Quotation to be Provided:

• Family Fun Center Application
• Photos as Described at End of Application
• Copy of the Daily Attraction Inspection Form Used
• Copies of Safety Manuals
• 5 Years of Currently Valued Loss History
• Copy of Most Recent Financial Statements of Business Tax Return

Please Indicate What Coverage is Being Requested at this Time:

Commercial General Liability

Excess Liability - Limits Available up to $5,000,000

• Limit Required:

Commercial Property (please indicate limits for coverage being requested)

• Building Limits:
• Contents Limits:
• Business Income Limits:
• Mobile Equipment Limits:
• Information Technology Limits:
• Crime – Employee Dishonesty Limits:
• Crime – Forgery of Alteration Limits:
• Crime – Theft, Disappearance, Destruction Limits:

Important Note: Coverage for mobile rental of inflatable games is excluded under this program. Please complete the Amusement / Inflatable Games Application or call 866.380.3372 for assistance with mobile game rentals.

Has business been in continuous operation for the last two years?  Yes  No

If no, please explain:

Operating season of park/facility: to

# of off-season events:

Total acreage of facility:

Patron Admission Costs:

Adults: $ Child: $ Discount: $

Proposed effective date of coverage:

Are you a member of a trade association?  Yes  No

If yes, trade association name:

Insurance Coverage / Limit Information

Limits of coverage requested: $

SIR/deductible: $ occurrence / $ annual aggregate

Previous insurance carrier information:

Year:
Liability Insurance Carrier:
Limits:
Annual Premium:
Incurred Losses (Paid/Reserved):

Please provide details of any individual loss in excess of $10,000:

Has any insurance carrier terminated coverage or declined your renewal?  Yes  No

If yes, please describe:

Facility Information

1. Does the Insured assume any liability for another party?  Yes  No
2. Does another party assume any liability for the Insured?  Yes  No
3. Total number of employees: Full Time: Part Time/Seasonal:
4. Do you have a full-time safety manager?  Yes  No
5. Are there any water hazards or unfenced bodies of water on your premises?  Yes  No
6. Do you have any “bulk” storage of flammable or hazardous materials?  Yes  No
7. Does the storage meet NFPA and local Fire Marshall standards and laws?  Yes  No
8. Is there a swimming pool on the premises?  Yes  No
9. Do you sponsor any sporting or social events?  Yes  No
10. Do you sponsor any type of competition?  Yes  No
11. Do you provide any live entertainment?  Yes  No
12. Do you have any indoor/outdoor special events where 250 or more spectators are present?  Yes  No
13. Do you maintain grandstands?  Yes  No
    Seating capacity: Construction:
14. Does the park/facility conduct fireworks displays?  Yes  No
15. Does the facility contain any of the following:
    Ice skating facilities?  Yes  No
    Parasailing?  Yes  No
    Roller skating facilities?  Yes  No
    Parachuting?  Yes  No
    Hang gliding?  Yes  No
16. Is playground equipment present?  Yes  No
17. Do you sell or serve alcoholic beverages?  Yes  No
18. Do you charge a fee for parking?  Yes  No
19. Do you have Valet parking?  Yes  No
20. Does your parking area have a hard, smooth surface?  Yes  No
21. If open after dark, are your parking areas lighted?  Yes  No
22. Does security patrol your parking areas?  Yes  No
23. Are patrons required to walk across public highways from the parking area?  Yes  No
24. Are all curbs, steps, and ledges highlighted?  Yes  No
25. Does your facility comply with current standards set by the Americans with Disabilities Act?  Yes  No
26. Does applicant own any other commercial property?  Yes  No
    
       If yes, please provide a copy of any written training material.
27. Do you have a written fire, disaster evacuation plan?  Yes  No
28. Will each attraction be supervised by an attendant or attendants?  Yes  No
    
    If no, please explain:
    
29. Are you contemplating any structural alterations, new construction, or demolition?  Yes  No
    
    If yes, please provide an explanation:
    

Security

1. Number of security personnel on staff:
2. Number of security supervisors: Number on Premises: Number off Premises:
3. Do any security personnel carry a firearm as part of their equipment while on duty?  Yes  No
   If yes, number of armed security personnel:
4. Are the security persons employed or contracted by the park? Employed Contracted
   (Employed: the individual is being paid and supervised directly by the insured. Contracted: the existence of a written contract with another entity for security services that has insurance coverage separate from the insured’s policy for security liability)
5. What are the staffing guidelines per number of patrons?
   
6. Are the guidelines determined by Ordinance or Statute?  Yes  No

Medical

1. Do you have staffed medical facilities?  Yes  No
2. Do you keep an ambulance on site?  Yes  No
3. Is it contracted from an outside firm?  Yes  No
       If no, is it owned by the center?  Yes  No
4. Distance to nearest hospital: Time by air:

Fire Protection

1. The fire department is staffed by: Professionals Volunteers
2. Do all public buildings have a sprinkler system?  Yes  No
3. Is there an independent water source such as on-site reservoir?  Yes  No
4. Is the nearest fire station within 5 miles or 5 minutes of the facility?  Yes  No
5. If more than 5 miles, is there a formal employee fire brigade?  Yes  No
6. Is there a fire alarm system on site?  Yes  No
7. Are fire hydrants and hoses strategically located and accessible?  Yes  No
8. Are fire extinguishers easily accessible in all buildings?  Yes  No
9. Are they checked: Monthly Annually Other (please specify):
10. Do you have at least one fire extinguisher for each attraction or building?  Yes  No
11. Do all indoor facilities comply with all local life-safety codes?  Yes  No
12. Do you comply with all local, state, building, concession, and sanitary codes?  Yes  No
13. Are exits from premises well marked?  Yes  No
14. How many exits from premises?
15. Is there an emergency lighting system on premises and in building(s)?  Yes  No
16. Are premises secured by a fence or building perimeter that is locked when facility is not open?  Yes  No
17. Are there smoking and non-smoking areas and are they clearly identified?  Yes  No
18. Is there a back-up emergency electrical power source for lights and communications?  Yes  No
    
    Please describe:
    

Photo Requirements

Photos should be submitted showing an overview of each attraction/ride plus a photo of the carrier (i.e. photo of the go-kart track plus a photo of one of the go-karts). Photos should be included showing any signage that is posted relating to the various attractions/rides.

Exposure:

Type of Event:

Operating Dates:

Beginning: Ending: Hours of Operation:

Fundraiser/Benefit (e.g., Jaycees, YMCA)

Private Club or Organization

Commercial– For Profit – Private Business Entity

Commercial Event – Sponsored by Local Business ventures (e.g., TV, Radio, Restaurant Promotion)

Do you require additional coverage for Setup or Teardown?  Yes  No

Number of Days:

ESTIMATED GROSS RECEIPTS

General Admission: $

Parking Receipts: $

Concession (including food and beverage – excluding alcohol) $

Alcoholic beverages (if any or N/A) $

Other $

Estimated Attendance Per Day:

Estimated Square Footage:

EMPLOYEE/VOLUNTEER SPECIFICATION -PROVIDE DETAILED INFORMATION FOR ALL "NO" RESPONSES

1. Your Volunteers or Employees cannot physically touch the customers during their skits.  Yes  No
   If No:
2. Your Volunteers or Employees are trained to deal with the public in this environment.  Yes  No
   If No:
3. Employees or Volunteers are 18 years or older.  Yes  No
   If No:
4. You provide adequate medical or first aid services on site during operating hours.  Yes  No
   If No:
5. Public parking areas are well lit and supervised.  Yes  No
   If No:
6. Volunteers or Employees keep walking surfaces clear of debris or obstacles.  Yes  No
   If No:
7. You prohibit the patrons from touching or interacting with the displays or skits.  Yes  No
   If No:
8. Displays do not include working power tools (e.g., saws, drills) or electrical shock machines or tricks.  Yes  No
   If No:
9. There are no low hanging ropes, nooses, props or displays crossing the customers path  Yes  No
   If No:
10. You do not permit the public to bring pets (dogs or other animals) on the premises.  Yes  No
    If No:
11. You do not use flammables, pyrotechnics, fireworks, firecrackers, orflashexplosives.  Yes  No
    If No:
12. You do not allow smoking on premises.  Yes  No
    • If No - Smoking signs are clearly posted and enforced  Yes  No N/A
    • You maintain designated smoking areas away from public or combustible materials.  Yes  No N/A

HAUNTED HOUSE SPECIFICATIONS:

PROVIDE DETAILED INFORMATION FOR ALL "NO" RESPONSES

Type of Building or Structure:

Free standing structure
Interconnected mobile trailers
Leased space in multi occupancy building (e.g., air supported former supermarket, store front, warehouse)
Temporary/Portable structure (e.g., dome or other structure erected for this event only)

 

1. The building meets all state, local, or governing agency life safety, fire and occupancy statutes, or requirements. (e.g., NFPA 101, Local Building Codes etc.)
    Yes  No
   If No:
2. The building has been inspected and approved for occupancy by the local fire authority.  Yes  No
   If No:
3. Employees or Volunteers are present throughout the facility during operating hours to monitor or assist patrons as they tour the displays.  Yes  No
   If No:
4. Uneven walking surfaces, steps, or flights of stairs are supervised by a designated Employee or Volunteer during operating hours.  Yes  No
   If No:

PROVIDE DETAILED INFORMATION FOR ALL "YES" RESPONSES

1. The haunted house is more than one story  Yes  No
   If Yes:
2. Patrons use slides to move from one level to another  Yes  No
   If Yes:
3. There are moving or sinking floors, or moving or sinking stairs.  Yes  No
   If Yes:

HAUNTED HAYRIDE/WAGON SPECIFICATIONS:

PROVIDE DETAILED INFORMATION FOR ALL "NO" RESPONSES

1. The unit is propelled by: Tractor Animal Locomotive Other motorized vehicle (explain)
   Explain:
   
2. The unit was specifically designed, and constructed by others to transport people.  Yes  No
   If No:
3. The unit has permanently mounted seats for riders.  Yes  No
   If No:
4. The unit is properly equipped to prevent riders from falling. (Guard rail, seat backs, handrails etc)  Yes  No
   If No:
5. Wheel wells are properly covered/protected to prevent accidental contact with any moving parts.  Yes  No
   If No:
6. You do not permit patrons to exit the unit before the entire trip is completed.  Yes  No
   If No:
7. You do not permit Employees/Volunteers to board the wagon after it has left the start area  Yes  No
   If No:
8. Operators are over 18 years of age and qualified operators of the unit.  Yes  No
   If No:
9. The unit does not operate on, or cross any public street, road, highway, or thoroughfare  Yes  No
   If No:

HAUNTED MAZE SPECIFICATIONS:

PROVIDE DETAILED INFORMATION FOR ALL "NO" RESPONSES

1. The maze was created by cutting pathways through growing crops  Yes  No
   If No:
2. If the maze is not cut through growing crops but consisting of walls made from of bales, you meet or exceed minimum thickness and stabilizing requirements for this type of construction.  Yes  No
   If No:
3. All walking areas are level and free of uneven surfaces.  Yes  No
   If No:
4. Your Employees or Volunteers monitor activities within the maze from a tower, bridge, platform, or other vantage point.  Yes  No
   If No:
5. There are adequate exits throughout the maze in the event patrons elect to exit without completing.  Yes  No
   If No:
6. You have a rodent/pest control program in place.  Yes  No
   If No:

HAUNTED WALKING TRAIL SPECIFICATIONS:

PROVIDE DETAILED INFORMATION FOR ALL "NO" RESPONSES

1. Your Employees or Volunteers guide patrons through the trail.  Yes  No
   If No:
2. Patrons may not leave the trail during the walk  Yes  No
   If No:
3. Patrons may not leave the group without completing the entire attraction  Yes  No
   If No:
4. All walking areas are level and free of uneven surfaces.  Yes  No
   If No:
5. Patrons are not permitted to climb on interact with skits or displays.  Yes  No
   If No:
6. Your Employees or Volunteers may not touch patrons as they walk past their display.  Yes  No
   If No:
7. There are no hanging ropes, or empty nooses in any of the displays.  Yes  No
   If No:
8. You have a rodent/pest control program in place.  Yes  No
   If No:

PRODUCTS/COMPLETED OPERATIONS

PRODUCTS SOLD OR DISTRIBUTED BY YOU	ANTICIPATED GROSS SALES

Attach literature, brochures, advertisements if available

Hay / Wagon Rides

Maze / Walking Trails

Mechanical Bulls Insurance Application

TYPE OF EVENT

Beer Garden/Beer Tent	Fund Raiser	Individual Vendor Booth
Car Show	Motor Vehicle Race/Show	Picnic
Concerts/Musical Performance	Competition or Show	Sporting Event/Tournament
Conventions/Trade Show/Exhibit	Parade	Wedding/Wedding Reception
Festival	Party/Social Event	Other (describe):

Location of event

Address:

City: State: Zip:

Will the event take place on the applicant’s premises?  Yes  No

Private Residence	Liquor-Licensed Establishment	Indoors
Convention Center	Stadium	Outdoors
Arena	Fair Grounds	Other (describe):

Is the applicant's premise located in a jurisdiction which permits civil cases to be heard in a Tribal Court?  Yes  No

Dates of event:

From: To:
(If one day event, end date should be the same as start date. Quote will contemplate coverage for events continuing past 12:00 AM).

Desired coverage date(s):

From: To:

If event date(s) differs from desired coverage date(s), explain:

Is set-up and take-down coverage needed for additional dates?  Yes  No
If yes, what are the dates and what will this exposure include?

Will there be any heavy machinery used?  Yes  No

Would you like to include a rain date?  Yes  No
If yes, what date?

FULL SCHEDULE/DESCRIPTION AND PURPOSE OF EVENT

Attach copy of brochure, website pages and flyer to this application
or include details on all activities taking place:

Will there be any entertainment?  Yes  No
If yes, describe and include name of performers and acts:

ESTIMATED TOTAL ATTENDEES PER DAY:

Average age of attendees:

If applicant is an individual exhibitor/vendor, what are the estimated attendees per day anticipated to visit their booth?

What is the maximum capacity of facility holding event?

Coverage desired: Commercial General Liability & Liquor Liability Commercial General Liability Only Liquor Liability Only

Limits of coverage desired:

HISTORY

1. Number of years event has been previously held:
2. Actual total attendance for prior year's event:
3. Previous carrier:
4. Policy number and premium:
5. Losses or claims during the past five years:

LIQUOR LIABILITY

1. ESTIMATED NUMBER OF ATTENDEES CONSUMING ALCOHOL DAILY:
2. Is applicant the sole vendor/server of alcohol at event?  Yes  No
   If no, list number of other vendors/servers serving alcohol:
   Are all participating alcohol vendors/servers required to carry liquor liability limits for the event?  Yes  No
   If yes, what is the minimum requirement?
3. Will alcohol be dispensed by a professional bartender?  Yes  No
   If no, describe how and by whom alcohol will be dispensed:
   Describe training and/or experience of persons serving alcohol:
   What measures are in place to prevent service of alcohol to minor and/or intoxicated persons?
4. If required, does applicant have a valid liquor license?  Yes  No
5. Is the applicant in the business of selling, serving or furnishing alcoholic beverages?  Yes  No
   Will alcohol be sold?  Yes  No
   If yes, estimated gross alcohol receipts per day:
6. Is BYOB (Bring Your Own Bottle) or self-service of alcohol permitted?  Yes  No

COMMERCIAL GENERAL LIABILITY

Will event feature any of the following:

1. Mechanical rides/devices?  Yes  No
2. Moon bounce, rock climbing wall, trampolines or similar rebounding devices?  Yes  No
   Describe:
   If yes, will a Certificate of Insurance be obtained for this exposure at the event?  Yes  No
3. Petting zoo or animal rides?  Yes  No
   If yes, will a Certificate of Insurance be obtained for this exposure at the event?  Yes  No
4. Firearms or fireworks?  Yes  No
5. Overnight camping?  Yes  No
6. Dunk tanks?  Yes  No
7. Water hazards?  Yes  No
   If yes, describe:
   Will attendees be permitted to swim, boat, jet ski or fish?  Yes  No
   If yes, describe:

Will the event use exhibitors, vendors, performers, contractors, sub-contractors or independent contractors?  Yes  No
If yes, explain:
Are they required to carry their own insurance?  Yes  No
What limit is required?

Describe security measures:

Is security provided by: Independent contractors Employees of applicant On-duty police

If security is provided by independent contractors, are they required to carry their own insurance?  Yes  No

If this is a CONCERT/MUSICAL EVENT, complete below:
(Please note, coverage for injury to performers and entertainers is excluded from our policy).

Name(s) of performer(s):

Describe type of music:

Performers are: Local National

If this is a PARADE EVENT, complete below:
(Please note, coverage for injury to parade participants is excluded from our policy).

1. Has parade route been approved by local authorities and will route be secured by police?  Yes  No
   If no, explain:
2. Are parade participants permitted to throw souvenirs, candy or other items into the crowd?  Yes  No
3. Describe parade route from start to finish:
   

If this is an ATHLETIC EVENT, complete below:
(Please note, coverage for injury to athletic participants is excluded from our policy).

1. Describe athletic event:
   
2. Professional Amateur
3. Is athletic participant’s coverage desired?  Yes  No

If this is a MOTOR VEHICLE RACE, RODEO, TRACTOR PULL OR TRUCK SHOW, complete below:
(Please note, coverage for injury to participants is excluded from our policy).

1. Is the venue designed specifically for this type of activity?  Yes  No
2. Are metal or concrete barriers in place to ensure spectator safety?  Yes  No
   If no, describe:
   
3. Are the barriers permanent?  Yes  No
4. How high are the barriers?
5. What is the distance between the barriers and spectators?
6. Will the venue provide a catch fence for the event?  Yes  No
7. Are spectators ever permitted in the pit or infield area?  Yes  No
8. Will event feature audience participation? (i.e. calf scrambles)  Yes  No
9. If this is a rodeo, are the transfer areas between animal pens and the competition restricted from the general public?  Yes  No

If this is a HEALTH FAIR/CONVENTION, complete below:

1. Will the event feature any medical or health treatment?  Yes  No

If this is a CAR SHOW/MOTOR VEHICLE SHOW, complete below:
(Please note, coverage for injury to participants is excluded from our policy).

1. Do vehicles remain stationary throughout the show with the engines off?  Yes  No
2. Will the event feature burnouts, drag races or flame throwing?  Yes  No

Wedding Events