Inflatable Jumper Application Form

	TOLL FREE: (888) 688-3788

This is an application for a General Liability Coverage. For Equipment / Property Coverage application please click here.
Please fill out the following form. You cannot save data typed into this form.
Please print your completed form if you would like a copy for your records.
(*) indicate required fields

GENERAL INFORMATION

Company Name *			Contact Name *
Number of Employees			FEIN/TAX ID
Currently insured *			Business Type *
Physical Address
Address *			City *
State *			Zip Code *
Mailing Address Same as my physical address
Address			City
State			Zip Code

Phone *			Fax
Email *			Website Address

INSURANCE INFORMATION

Proposed effective date *			Gross annual revenue*
Date business started under current ownership *			Title(position)
Type of operation *
Any Insurance policy or coverage declined, canceled or non-renewed during the prior 3 years:
Brief description of the business operations/activities*:

INVENTORY LIST

Inflatables and Mechanical rides
Attach Separate Inventory List Below If Needed

Items (including non-inflatable)	Sizes Length x Width x Height	Price
		$
		$
		$
		$
		$
		$
		$
		$
		$
		$
		$
		$
		$
		$
		$
		$
		$
		$
		$
		$

Non Inflatable Items (Tables, Chairs etc.)

Items (including non-inflatable)	quantity	Price
		$
		$
		$
		$
		$
		$
		$
		$
		$
		$
		$
		$
		$
		$
		$
		$
		$
		$
		$
		$

GENERAL LIABILITY COVERAGE LIMIT

Occurence	Aggregate

DOCUMENT UPLOAD

Please Include Your Rental Agreement

Please Include Inventory list

Please Include Loss Run

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