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Amusement Application
Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.
Personal Information
Additional Information
Attraction 1
Attraction 2
Attraction 3
Attraction 4
Property Supplement
Personal Information
Date
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First Name
Required
Last Name
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Contact Person
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Primary Phone Number
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Fax Number
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If Other, Please Specify
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Website URL
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Years In Business
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Expiration
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Interest In Premises
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Owner
Tenant
Other Occupancies
Optional
If yes, receipts $
Optional
Trade Associations which insured belongs to:
Optional
Prior Insurance Carrier
Optional
Has insurance ever been
Optional
Cancelled
Declined
Non-renewed
Additional Insureds / Address
Optional
Franchiser
Optional
Lessor
Optional
Other
Optional
Additional Information
Total Gross Receipts
Optional
# Annual Admissions
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Hours of Operation
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Parking Facilities
Optional
Yes
No
If yes,
Optional
Owned
Leased
Describe Security (armed/unarmed)
Optional
Is security present during open hours?
Optional
Yes
No
Is security present during closed hours?
Optional
Yes
No
Do you provide baby-sitting / day care?
Optional
Yes
No
If so, child to attendant ratio
Optional
Please explain service
Optional
Describe first aid facilities
Optional
Distance to ambulance / respone time:
Optional
Emergency lighting?
Optional
Yes
No
Do you have special events such as concerts or fireworks displays?
Optional
Yes
No
Attraction Information
Arcades
# of Units
Optional
Receipts $
Optional
# of Attendants
Optional
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Does the insured own or lease games?
Optional
Own
Lease
Who provides service / maintenance on machines?
Optional
Non-slip, Non-conductive floor covering?
Optional
Yes
No
Are all machines properly grounded?
Optional
Yes
No
Batting Cages
None?
Optional
Yes
No
# of Units
Optional
Receipts $
Optional
# of Attendants
Optional
select
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Minimum Age
Optional
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Are helmuts required?
Optional
Yes
No
Are cages completely closed?
Optional
Yes
No
Bumper Boats
None?
Optional
Yes
No
# of Units
Optional
Receipts $
Optional
# of Attendants
Optional
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Manufacturer
Optional
Maximum engine HP
Optional
Age / height requirements
Optional
Is the depth of water 4 feet or less?
Optional
Yes
No
Height of observation fence:
Optional
Bumper Cars
None?
Optional
Yes
No
# of Units
Optional
Receipts $
Optional
# of Attendants
Optional
select
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Manufacturer
Optional
Oldest Unit
Optional
Age / height requirements
Optional
Are cars equipped with a dash pad and headrest pad?
Optional
Yes
No
Type of seatbelts?
Optional
Wheel pads on steering wheels?
Optional
Yes
No
Climbing Walls
None?
Optional
Yes
No
Receipts $
Optional
# of Attendants
Optional
select
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Who built the wall?
Optional
What safety equipment will the participants be using?
Optional
Does your organization have an inspection policy and/or practices in place for all critical safety equipment?
Optional
Yes
No
Describe your equipment check policy for wall, hardware, and rental gear. Are records kept?
Optional
Do particapnts sign waivers? If yes, please attach a copy.
Optional
Yes
No
Concessions / Novelty Items
None?
Optional
Yes
No
# of Stands
Optional
Receipts $
Optional
Square footage:
Optional
Describe goods sold:
Optional
Are food operations handled by insured or subcontractor?
Optional
Yes
No
If subcontracted, is certificate collected?
Optional
Yes
No
Is there cooking on the premises?
Optional
Yes
No
If so, is there a grill?
Optional
Yes
No
Is there a deep fryer?
Optional
Yes
No
Is there an automatic ansul system protecting cooking/frying surfaces?
Optional
Yes
No
Hood ducts cleaned by contractor:
Optional
Monthly
Quarterly
Golf Driving Ranges
None?
Optional
Yes
No
# of Stalls
Optional
Receipts $
Optional
Are there partitions between stalls?
Optional
Yes
No
Describe partitions between tee boxes
Optional
# of Levels
Optional
Other attractions exposed to range?
Optional
Go Karts
None?
Optional
Yes
No
# of Single Karts
Optional
# of Double Karts
Optional
# of Tracks
Optional
Receipts $
Optional
# of Attendants
Optional
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# of Extinguishers / Type
Optional
Track rules and safety signs clearly posted?
Optional
Yes
No
Minumum age/height requirements
Optional
Maximum speed of karts (MPH)
Optional
Are governors installed?
Optional
Yes
No
Manufacturer
Optional
Are helmuts required?
Optional
Yes
No
Roll bars
Optional
Yes
No
Bumperguards
Optional
Yes
No
Operator cut off system
Optional
Yes
No
Are spectators separated from track?
Optional
Yes
No
Padded steering wheel?
Optional
Yes
No
Is there a headrest support
Optional
Yes
No
Do operators sign waivers?
Optional
Yes
No
Type of track surface?
Optional
select
Slick
Dry
Do you allow racing?
Optional
Yes
No
Do you allow timed runs?
Optional
Yes
No
Track fenced?
Optional
Yes
No
Do fences meet ASTM F24 requirements?
Optional
Yes
No
Type of barrier?
Optional
Amount of gas on premises
Optional
How stored?
Optional
Where is gasoline stored?
Optional
How far away from track?
Optional
Inflatables
None?
Optional
Yes
No
# of Units
Optional
Receipts $
Optional
# of Attendants
Optional
select
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Do inflatables have signs clearly indicating age, height, or size limitations?
Optional
Yes
No
Are your inflatables inspected by the state and/or your employees?
Optional
Yes
No
Are all inflatables manned by an operator/attendant?
Optional
Yes
No
Do you rent inflatables?
Optional
Yes
No
If yes, please answer the following
Are they rented with operators/attendants?
Optional
Yes
No
Do you deliver the inflatables?
Optional
Yes
No
Do you set up the inflatables?
Optional
Yes
No
Do you tear down the inflatables?
Optional
Yes
No
Do you use the manufacturer's checklist for the set up and use of the equipment?
Optional
Yes
No
When inflatables are used outdoors, are there procedures to suspend use during inclement weather?
Optional
Yes
No
Kiddie Rides
None?
Optional
Yes
No
# of Units
Optional
Receipts $
Optional
# of Attendants
Optional
select
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Are all rides in full compliance with ASTM F24 Standards?
Optional
Yes
No
Coin-operated?
Optional
Yes
No
Ride Name
Optional
Age / height requirements
Optional
Manufacturer
Optional
Ride Name
Optional
Age / height requirements
Optional
Manufacturer
Optional
Ride Name
Optional
Age / height requirements
Optional
Manufacturer
Optional
Ride Name
Optional
Age / height requirements
Optional
Manufacturer
Optional
Laser Tag
None?
Optional
Yes
No
Receipts $
Optional
# of Attendants
Optional
select
1
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Minature Golf
None?
Optional
Yes
No
Total # of Holes
Optional
# of Courses
Optional
Receipts $
Optional
# of Attendants
Optional
select
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Do fountains and waterfalls have ground fault interrupters in place?
Optional
Yes
No
Paintball
None?
Optional
Yes
No
Receipts $
Optional
Repair Receipts $
Optional
Equipment Sales $
Optional
Minimum Age
Optional
select
0
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Maximum # of participants per game
Optional
Total square footage of playing area
Optional
Are waivers signed by all participants?
Optional
Yes
No
Are written instructions and procedures provided to all participants?
Optional
Yes
No
Are partcipants whom violate the safety rules ejected?
Optional
Yes
No
Are participants separated by level of experience?
Optional
Yes
No
What is the raio of participants to judges?
Optional
Are spectators properly protected from the paintball area?
Optional
Yes
No
Do you have special events such as tournaments, league play, etc?
Optional
Yes
No
Address
Optional
Does all equipment meet ASTM standards?
Optional
Yes
No
What type of protective gear is supplied to participants?
Optional
What type of air system is used?
Optional
Are barrel plugs or socks mandatory?
Optional
Yes
No
What is the feet per second (fps) used at your facility?
Optional
What is the average age of rental equipment?
Optional
Do you repair or modify equipment sold?
Optional
Yes
No
Do you sell US made products?
Optional
Yes
No
Do you purchase products through a US wholeseller?
Optional
Yes
No
Do manufacturers provide certificates of insurance naming you as an additional insured?
Optional
Yes
No
Do you have a formal maintenance plan?
Optional
Yes
No
How often is equipment inspected?
Optional
Soft Play / Ball Crawl
None?
Optional
Yes
No
Receipts $
Optional
Describe
Optional
Number of employees supervising play area
Optional
Are there signs indicating age, height, or size limitations?
Optional
Yes
No
Property Supplement
City
Optional
State
Optional
ZIP / Postal Code
Optional
Fax
Optional
Types of coverage looking for (need gross sales broken down by each activity)
Optional
Liability
Property
Excess
ECT.
Hold down the Ctrl Key to make multiple selections.
Facility Activities (need values of all prop to be insured)
Optional
Go-Kart
Laser Tag
Inflatables
Bowling
Mini-Golf
Batting Cages
Paintball
Arcade
ECT.
Hold down the Ctrl Key to make multiple selections.
Expiration date of current policy
Optional
Current Insurance Company
Optional
Current Premium
Optional
Years In Business
Optional
select
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Gross Sales
Optional
Property Info
Building Value
Optional
Contents Value
Optional
Updates
Optional
Roof
Wiring
Plumbing
Heating
Alarmed
Optional
Burglared
Fire
Nearest Fire Hydrant (FT)
Optional
Distance to Fire Station (Miles)
Optional
None?
Optional
Yes
No
Enter Validation Code
Required
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