Amusement Application

Personal Information
Date Required Date is required.
First Name Required Input Required
Last Name Required Input Required
Doing Business As Optional
Contact Person Optional
Street Required Input Required
City Required Input Required
State Required Input Required	select AL AK AZ AR CA CO CT DE FL GA HI ID IA IL IN KS KY LA ME MD MA MI MN MS MO MT NC ND NE NV NH NJ NM NY OH OK OR PA PR RI SC SD TN TX UT VT VA WA DC WV WI WY AB BC MB NB NL NS NT NU ON PE QC SK YT
ZIP / Postal Code Required Input Required Please enter a valid Postal code.
Primary Phone Number Required Input Required Please enter a valid phone number
Fax Number Optional
E-Mail Address Required You must provide an e-mail address. A valid e-mail address is required.
Insured Is Required Insured Is is required.	Corporation Partnership Individual Joint Venture Other
If Other, Please Specify Optional
Website URL Optional
Years In Business Optional	select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
Proposed Effective Date Optional	Open the calendar popup. << < February 2012 > >>   S M T W T F S 5 29 30 31 1 2 3 4 6 5 6 7 8 9 10 11 7 12 13 14 15 16 17 18 8 19 20 21 22 23 24 25 9 26 27 28 29 1 2 3 10 4 5 6 7 8 9 10
Expiration Optional
Interest In Premises Optional	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 Optional
Hours of Operation Optional
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	select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
Minimum Age Optional	select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
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	select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
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	select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
# 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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
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 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
Minature Golf
None? Optional	Yes No
Total # of Holes Optional
# of Courses Optional
Receipts $ Optional
# of Attendants Optional	select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
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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