General Liability – This is the application for a General Liability Coverage Want create site? Find Free WordPress Themes and plugins.For Inland Marine business Equipment and/or Property Coverage application please click here. General Liability - 1 Company Info2 General Info3 Policy Claims4 Supplements5 Equipment6 Fraud Page7 Submission Requirements Please fill out the following form. (*) indicate required fieldsSection 1: POLICY RECOMMENDATIONS(Please check any you are interested in) General Liability Earthquake Worker's Compensation EPLI Hired & Non-Owned Auto Abuse/Molestation Accident Medical Inland Marine Commercial Auto Flood Umbrella Cyber Liability Submission Requirements1) Loss Runs (5 years) 2) No loss letter if operating with no insurance 3) Copy of Rental Agreement / Waiver4) Safety Rules 5) Pictures of signage with hold harmless wording (Pay for Play Only)Section 2: COMPANY INFORMATIONHow did you hear about us?-Select-BingCustomer ReferralEmail BlastGoogleManufacturerOtherPostcardSocial MediaTrade ShowYahooAre you an ERS or Inflatable Office customer?*YesNoCorporate Name*Business Name*First Name*Last Name*Date of Birth:* FEIN/SS#:*Your FEIN/SSN must consist of at least 5 charactersPhone Number:*Fax Number:Your Email Address* Enter Email Confirm Email WebsiteEntity Type:*-Select-IndividualPartnershipCorporationLLCJoint VentureExamples: Individual: Jane Doe DBA Jane's Bouncers, Partnership: Jane Doe & John Smith, Corporation: C Corp or S Corp, LLC: Jane's Bouncers LLCYear Business Started (Month/Year)* MM DD YYYY Years of Management Experience:*Does not have to be with inflatables. Enter none if no experienceType of Management Experience:*Do you ever process payment cards?*YesNoEstimated annual number of payment card transactions:*Mailing Address* Mailing Address: City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Location Address Location Address: City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Operation type?*with operators - Employee staffed eventswithout operators - Backyard birthday partiesbothWith Operators - Projected Annual Gross Sales:*Without Operators - Projected Annual Gross Sales:*Desired Effective Date: Describe your operations- Check all that apply: Backyard Birthday Parties Parks Corporate Events Street Fairs Carnivals Events where you charge each participant Do you or your company operate any Street Fairs, Carnivals or Midways?*YesNo Save and Continue Later Section 3: GENERAL INFORMATIONComplete the following information, where applicable:Describe/list specialized training - Check all that apply: SIOTO IAAPA Manufacturer Other Do you allow overnight rentals?*YesNoDo you have people that work for you?*YesNoHow many attendants/operators accompany each piece of equipment at the rental site?-Select-Renter12 or moreIs equipment ever left unattended while set up at an event?*Carnivals, Festivals, etcYesNoAre the inflatables set up on flat surface & properly secured?*YesNoDo you have Watchdog Siren Warning Devices?*YesNoDo you allow adults & children to jump at the same time?*YesNoAre there age, height & weight limits displayed clearly on all devices?*YesNoAre Rental Agreements signed by renters of the equipment?*YesNoDoes your rental agreement contain hold harmless wording, release of liability and safety rules?*YesNoHow is equipment transported to and from events?*Do you maintain & operate equipment in accordance with manufacturer's instructions?*YesNoHow often is equipment inspected for damages/safety?*Before & after each useWeeklyOtherDo you keep a written log for repairs?*YesNoCustomer Pick Up?*YesNoDo you want coverage on the units for fire, theft, vandalism and/or business income?*This will be an additional premium, you will need to provide serial numbers and values of your units.YesNoAre you a dealer or distributor of new or used inflatables, rides or equipment?*YesNoDo you subcontract equipment from other rental companies?*YesNoPlease attach your rental agreement by clicking on the browse button.FOR DUNK TANKS:Manufacturer of Tank:What year was it manufactured?Please attach a picture of the dunk tank by clicking on the browse button.FOR ZORB BALLS:Are they used on a track?YesNoAny downhill usage?YesNo Save and Continue Later Section 4: POLICY CLAIMSPLEASE COMPLETE ALL THE ITEMS BELOW FOR YOUR PREVIOUS POLICY INFORMATION:General LiabilityCompanySales $Deductible $Policy Date LimitsPremiumPropertyCompanyProperty Off PremiseBuilding ValueContentsPremiumPayroll $Property Date Limits# of TrailersBusiness Income $AutoCompanyPolicy Date LimitsPremiumRadius# of Trucks# of Vans# of Priv. PassUmbrellaCompanyLimitsPolicy Date PremiumPlease Indicate the claim year, type, quantity, and amount incurred in the last three years: (If none just leave set to none)Year of claims:Claim Type:No. of claims:Total Amount: Year of claims: 2015, 2014, 2013, 2012 Save and Continue Later Section 4: DEVICE SUPPLEMENTS - MECHANICAL BULL SUPPLEMENTDo you own a Mechanical Bull?*YesNoFull Time:*Part Time:*Annual Payroll:Names of all operators:If independent contractors are ever used to operate, est. annual costs for such labor $Section 2: BULL INFORMATIONOperation of Bull(s) is:*FixedMobilePhysical Description of Bull(s)How many mechanical bulls do you own:Select1234If Galaxy bull, what model is it?RegularDeluxeBothIs bull electric?*YesnoDoes each device have an emergency shut off?*YesnoIs each device equipped with variable speed controls?*YesnoDoes the device have soft horns?*YesnoDoes the device have soft horns?*YesnoDoes the device have a padded head?*YesnoYears in business:# of Bulls Owned:Annual Gross Revenue:Section 2b: SITE SET-UPMinimum Fenced Radius of 10 feet or more?*YesNoDoes device have enclosed inflatable arena with a min. 16 inch inflatable landing?*YesNoMinimum ceiling / overhead clearance of 12 feet or more?*YesNoBase of unit completely covered with padding?*YesNoList of venues where ride will be operated (check all that apply):Bars/Taverns/Night ClubsPrivate PartiesRodeosCarnivals/FairsMechanical Bull Riding Competitions where prizes awardedOther (describe)Is alcohol served by the venue where the mechanical bull is present?YesNoDo mechanical bull operators monitor for patron alcohol use?*YesNoSection 3: Operational Related SafetyNOTE: Remember not to hit your back button or your refresh button so that you do not accidentally erase or wipe out any type of information that you have typed in.Month / Year of last inspection by a certified / independent inspector?*Do operators have test procedures provided by the manufacturer to: Determine if ride is operating within mfr’s prescribed limits?*YesNoEvaluate product wear?*YesNoDo operators have mfr’s manual describing proper operation / schedules of routine inspections required / required maintenance?*YesNoAre all ride operators at least 19 years of age?*YesNoNumber of operators supervising use of the unit at any one time?*Are operators trained to strictly enforce all rules / regulations even if it means stopping a ride early or refusing a ride to a customer?*YesNoWhat is the minimum age requirement you mandate for any rider?*Section 3b: Liability WarningsAre warnings transmitted to prospective riders in advance by way of conspicuously posted signs or otherwise (preferably bilingual in English / Spanish) as pertains to:a. Participants are required to sign waiver of liability before participating in any rides.*YesNob. No one under the age of 18 can ride without the presence of their parent or legal guardian, and such parent or legal guardian are required to sign waiver of liability for that rider.*YesNoc. Rider is participating at their own risk, and neither ride owner nor operator is responsible for accident or injury to any person arising out of the mechanical bull ride.*YesNod. Individuals with pre-existing conditions such as back, neck, leg, or arm injuries are not permitted to ride. However, ride operator is not responsible for determining the physical condition or ability of any rider.*YesNoe. Participants may request that the ride be stopped at any time.*YesNoDoes operator check photo ID to verify participant is same individual and age?*YesNoAre Waivers signed in the presence of the operator or other attending employee?*YesNoHow long are signed waivers retained?Where stored?Does operator verbally ask about pre-existing injuries, and if any, refuse the ride?*YesNoAre your operators instructed to require riders under the age of 18 to wear helmets?*YesNoNote: This application MUST include a copy of the Waiver of Liability / Rider Release form used. Such form MUST include a hold harmless agreement in favor of both ride owner and operator as well as outline all terms and conditions the participant agrees to follow. Bilingual language is preferred (English/Spanish)FileSection 4: MISCELLANEOUSNOTE: Remember not to hit your back button or your refresh button so that you do not accidentally erase or wipe out any type of information that you have typed in.Do you ever allow free rides?YesNoIf yes, explain under what circumstances and approximate number per year:Prior General Liability Insurance Company:Expiration Date:Premium:Describe all claims arising out of your mechanical bull units for the past 4 years:Provide a diagram of the operational area to include placement of bull, area of padding, location of fencing or other barriers, distances to spectator area, walls or any other obstructions.Attach Diagram:Section 4: DEVICE SUPPLEMENTSIf you have any of the following devices please fill out the supplemental information. If you do not own any of the devices below please answer no for each section to proceed.Rock Wall SupplementDo you own a Rockwall?*YesNoManufacturer:*American Rock ClimbingVertical RealityExtreme EngineeringSpectrum Sports/Rebound Active SportsOtherIs it an inflatable Rockwall?*YesNoIf yes, is it Manual or Auto Belay:*ManualAutoThe Rockwall is:*IndoorOutdoorRockwall supervised at all times:*YesNoIs there a formal maintenance checklist program:*YesNoIs there a formal employee safety training program?*YesNoIs the tool loop cut off from the safety harness?*YesNoWhen the rockwall is not used, how and where do you store it?*How often are the cables replaced?*Rockwall Belay is:*ManualAutomaticDate Rockwall manufactured?*Trackless Train SupplementDo you have a Trackless Train?*YesNoManufacturer:*How many cars?*Back Brakes?*YesNoDoes the train have a rearview mirror to view the last cars?*Who is the conductor?*Is train run at a mall or strip mall?*YesNoIf yes, which one?*Strip MallMallIs this an outdoor mall?*YesNoDoes landlord have special insurance requirements?*YesNoIs the train driven in areas where there is moving traffic, such as parking lots or outdoor malls (driveways & roads or pedestrian walkways)?*YesNoIf yes, describe the route in detail:Are Customers:* Residential Corporate Fairs & Festivals Traveling Carnivals How is train transported to event sites?*Is there waiver signage on or near the train, clearly visible to all participants?*YesNoPlease attach a photo of your trainPlease send a copy of the waiver signage WordingSection 4: DEVICE SUPPLEMENTS - BUNGEE TRAMPOLINE SUPPLEMENTDo you own a Bungee Trampoline?*YesNoAnnual Receipts:*Location of Eurobungees:*EurobungeesHow many?Manufacturer YearSupport Pole HeightManufacturer/ModelTrampoline Dimensions HarnessesManufacturerNumber on HandReplacement FrequencySize/Model TypeAge of Oldest OneDate last replaced Bungee CordsManufacturerNumber on HandReplacement FrequencySize/Model TypeAge of Oldest OneDate last replaced CarabineersManufacturerNumber on HandReplacement FrequencySize/Model TypeAge of Oldest OneDate last replaced More InformationWhat is the maximum jumping height capacity?*How old is the jumping surface of each trampoline?*Do you always fit harnesses to the size of each person?*YesNoAre all attendants trained on manufacturer specifications for fitting harnesses?*YesNoDo you always adjust the bungee cords according to manufacturer recommendations for the weight and height of each user?*YesNoAre all attendants trained on manufacturer requirements for bungee cord adjustment?*YesNoDo you require users to comply with age, weight and height restrictions?*YesNoWhat are the minimum and maximum age requirement for users?*MinimumMaximum What are the minimum and maximum weight restrictions for users?*MinimumMaximum What are the minimum and maximum height restrictions for users?*MinimumMaximum How do you verify weight/height when user size visually appears to be over the limit?*Does your waiver indicate any user restrictions noted by the manufacturer?*YesNoDo you always maintain a one to one ratio of attendant supervision for each person on a trampoline?*YesNoDo you always restrict users to one at a time per trampoline?*YesNoIs there a barrier or fence around the attraction to prevent pedestrian or observation traffic in the jumping area?*YesNoIs access to area around attraction restricted to attendants and one user per attraction?*YesNoAre user restrictions, warning and safety signs clearly posted by the entrance to the attraction?*YesNoDo you inspect all the equipment daily?*YesNoDo you document your inspections with a written checklist and findings?*YesNoHow long are records of inspections maintained?*Describe the experience of the person(s) in charge of inspecting an supervising use of the bungee jump trampolines.*Is this equipment always attended when set up?*YesNoIs this equipment located in one site or moved from site to site?*Do you always set up and take down the equipment if moved from the site?*YesNoDo you fully test and inspect the equipment after each set up?*YesNoHow long do you retain the records of testing and inspecting your set up?Do all users sign and date a waiver and release document?*YesNoDo you fully test and inspect the equipment after each set up?*YesNoHow long do you retain the records of testing and inspecting your set up?Do all users sign and date a waiver and release document?*YesNoAre minors required to have a parent or legal guardian sign the waiver?*YesNoAttach Copy of Waiver & Release DocumentDo you use a written checklist to document your testing and inspecting after each set up?YesNoDoes your waiver require signing party to represent in writing that they are over 18?YesNoDo you require a legibly printed name of the signing party on your waiver?YesNoIs secured padding provided over the trampoline springs and frame perimeter?YesNoIs the flooring beneath and surrounding the perimeter of the attraction padded?YesNoWhat is the height clearance between the highest point of the attraction and the ceiling?*What is the perimeter clearance maintained around each attraction?*Were all attractions addressed on this supplemental application inspected and found satisfactory by a state or local authority?*YesNoPlease provide the date of last inspection, testing authority, and any applicable certificate or inspection number. Save and Continue Later Section 5: Equipment ListYou must list all inventory/operations to include: Tents, Tables, Chairs, Concessions, Face Painting, Balloon Twisting, Characters, DJ's, etc. Please enter in your inventory by answering the questions below:Do you have inventory that is stored at different locations?YesNoOr attach an Excel or PDF Inventory List.How many locations?Select#12345678910How many pieces of equipment do you own:Select#12345678910How many pieces of equipment do you own:Select#12345678910Units must be listed/named as they are on your Website/Facebook pge.*LocationManufacturerItem TypeItem Namewrite if not found on list Units must be listed/named as they are on your Website/Facebook pge.*ManufacturerItem TypeItem Namewrite if not found on list Please make sure that you have completed everything to the best of your knowledge before going to the next page. Save and Continue Later Section 5: FRAUD STATEMENTGENERAL STATEMENT: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and [NY: substantial] civil penalties. (Not applicable in CO, DC, FL, HI, KS, MA, MN, NE, OH, OK, OR, VT or WA; in LA, ME, TN, and VA, insurance benefits may also be denied) APPLICABLE IN COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement of award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. APPLICABLE IN THE DISTRICT OF COLUMBIA: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant. APPLICABLE IN FLORDIA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. APPLICABLE IN HAWAII: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. APPLICABLE IN KANSAS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. APPLICABLE IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties. APPLICABLE IN MINNESOTA: Any person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. APPLICABLE IN OHIO: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deception statement is guilty of insurance fraud. APPLICABLE IN OKLAHOMA: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. APPLICABLE IN WASHINGTON: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. I understand that the insurance company, in determining in whether to provide insurance coverage, will rely on the information contained in this form and all other information submitted. I hereby warrant, represent and confirm that, to the best of my knowledge, all information provided is complete, true and correctPerson Applying:*Date Submitted: Save and Continue Later Section 6: SUBMISSION REQUIREMENTSIn order to process your application we need you to attach the following documents:* Completed Application with all Questions Answered Loss Runs (5 years)*No loss letter if operating with no insurance*Copy of rental agreement or waiver*Picture of signage with hold harmless wording (Pay for Play Only)*Safety Rules*WARRANTY(Applies to all parts of this application and attachments submitted) It is hereby understood and agreed that if insurance is issued by virtue of completing this application and any applicable supplemental applications, the Insurance is only issued on the reliance on the applicant’s warranty of answers to the questions above and on any such supplemental applications. If, at the time a certificate/policy is issued and ANY OF THE ABOVE WARRANTIES IS IN ANY RESPECT INCORRECT, INCLUDING CLAIMS OR GROSS RECEIPTS, THE COVERAGE AFFORDED UNDER THE CERTIFICATE/POLICY shall, without notice to the applicant, immediately and automatically cease, & the certificate/policy shall BECOME NULL AND VOID. Warranties will survive a certificate/policy if issued.Person Applying:*Title:*Date Submitted:* Save and Continue Later Did you find apk for android? You can find new Free Android Games and apps.