Named Insured:

Date:

Contact Name:

Phone:

Form of Business: Corporation: Partnership:
Sole Proprietor: Other:

FEIN:


Mailing Address:

City:

State:

Zip:

E-Mail Address:

Web Page Address:

Location Address:

City:

State:

Zip:

Is this an off-premises rental business? Yes No

If no, describe

Desired Effective Date:

Is this a new business?

Detailed decription of business activities:

Date business started:

Years experience in industry:

Any training or certificates?

Expalin:

Do you provide employee instructions? Yes No Explain

Do you currently have a general liability policy? Yes No Carrier

Provide Declarations Page (first page of policy) Expiring Premium

Provide 5 Year Loss Runs (claims history). Please provide details of any incurred loses.

Are you a member of IIP & GA? Yes No

* International Inflatable Products and Games Association

Has any policy or coverage ever been declined, cancelled, or non-renewed? Yes No

Do you have any animal rides or animal exposure? Yes
No If yes, please describe

For amusement rides, describe the height and type of fencing required for spectator safety

Do units/rides have signs marking age, height, and size limitations? Yes

No

Please explain limits

Are all units/rides inspected? Yes No If yes.please provide details of the inspection process, including who completes, frequency and if inspection/maintence logs are maintained.

Estimated Annual Sales$

Do you set up your own devices? Yes No

Do you stay in attendance while in operation? Yes No If no, is a waiver/release of libality used? Yes No Please describe the nature of the adult supervision provided while any ride or device is in use.

Is this is a rental business, it is a conditon of coverage that a copy of the rental agreement and/or release of liability from be submitted with this application. No coverage will be provided unless this condition is met. Attach copy of rental agreement.

List states in which you operate

Total number of employees Are emplyees leased? Yes No Annual Payroll

Do you have a training program?
Any person who knowingly and with intent to defraud any insurance company or other person files am application for insurance containting any false information or conceals information concerning any face materal thereto, for the purpose of misleading, commits a fraudulent insuracne act, which is a crime.

Applicatant"s Signature:

FEIN # or Soc Sec #

Date:

Agency/Producer Signature

Date: