Fall Festivals Quote Application Step 1 of 2 50% Any amusement attraction, device, activity or special event not listed on this application will not be considered or contemplated within our quote. Any amusement attraction, device or activity listed is still subject to underwriting approval. Please read our quote carefully to determine what is considered/contemplated with our quote and what amusement attraction, device or activity is excluded or not part of our quote.Applicant InformationInsured Name* Mailing AddressStreet* City* State*StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code* Event Name/AddressName* Street* City* State*StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code* Website Address* Applicant is* Individual Corporation Partnership Joint Venture Contact First Name* Contact Last Name* Phone*FaxEmail Address* Hours of Operation:Spring: Open?* Yes No Days/Hours of Operation:* Summer: Open?* Yes No Days/Hours of Operation:* Fall: Open?* Yes No Days/Hours of Operation:* Winter: Open?* Yes No Days/Hours of Operation:* Event InformationEvent Description:*Attach any promotional material Drop files here or Select files Max. file size: 256 MB. Haunted Hayride* Yes No Effective Date* End Date* Date Business Established* Estimated Attendance*Last Year's Attendance*Max Capacity at Event Location*Price of Admission*Estimated Gross Attraction Receipts*Estimated Gross Attraction Receipts (Estimated Attendance x Price of Admission)Estimated Food Receipts*Estimated Merchandise Receipts*Prior Year Gross Receipts*Attendee Age Demographic* Minimum Age* Special Concerns for Children* Event is Held* Indoors Outdoors Both Fenced* Yes No Crowd Control/Security Personnel* Ushers Private Security Off-Duty Police How Many?* Security Guards used?* Yes No Armed Unarmed If using hired security, are certificates of insurance obtained?* Yes No Is applicant named as additional insured?* Yes No Describe procedures and protocols:* How Many Personnel?* Employee Type and Numbers* Regular* Leased* Volunteer* Is Workers' Compensation Coverage in Force?* Yes No Estimated Payroll*Will bleachers or platforms be used?* Yes No Will they have back and side rails?* Yes No Are food and beverages sold on the premises?* Yes No Outside vendor?* Yes No Food types available* Cooking methods if cooked on site* Alcoholic beverages served* Is Liquor Liability policy in force?* Yes No Is Liquor sold by 3rd party vendor?* Yes No Is applicant named as additional insured?* How are guests escorted?* Lead Guides* Yes No How many Lead Guides?* Follow-up Guides* Yes No How many Follow-up Guides?* Door Monitors* Yes No How many Door Monitors?* Max. Group Size* Does Insured operate Haunted House at this location?* Yes No If so, please complete the haunted house supplement.Is the Insured (owner) of this facility CHAOS (Certified Haunted Attraction Operator Seminar) certified?* Yes No Please attach copy of certification* Drop files here or Select files Max. file size: 256 MB. Certification is required a minimum of every other year.Special Effects and Devices:*Part of a Haunted Attraction?* Yes No Strobe Lighting* Yes No Other Events or Attractions at the Same Site:*+Some exclusions include, but are not limited to: Patron Touching, Rat Racers/Rat, Livestock Coverage, Electrical Shock Devices, Rollers Water Activities.Applicant HistoryDescribe applicant's experience with Fall Festivals including years, numbers, and dates:*Premium and Loss Record for the Last Five YearsPremium and Loss Record for the Last 3 Years:*For each year, please list policy period, carrier, premium, loss amount, and non-renewal or cancel.Please attach Loss Runs from your prior Insurance Carrier(s), for the past 3 years. If this is your first year in business, please disregard. If you have been with Donat Insurance Services, LLC, for the past 3 years, please disregard. Drop files here or Select files Max. file size: 256 MB. Describe details of losses/incidents for the past 3 years:Liability SupplementApplicant Name* Rides and Attractions - Do you have the following:Petting Zoo* Yes No Animals must be hand-led or tethered.Type of Animals:*Exotic or Dangerous Animals* Yes No Animals Fenced In* Yes No Spectator Touching* Yes No Hand Washing Stations* Yes No Horse-drawn Carriage Rides* Yes No Hay Rides* Yes No Drivers must be 25 years and over. Wagons must have 3-foot sides and must be pulled by a farm implement tractor.Off Premises or on Public Roads* Yes No Night Rides* Yes No Does trail have any lighting?* Yes No Max. % Grade at Steepest Part of Trail* If Hay Ride Loading/Unloading Area has more than a 2% incline, it must have 2 Operators. Operator 1 - Driver of the Tractor: MUST REMAIN IN TRACTOR AT ALL TIMES. Operator 2 - MUST REMAIN AT REAR OF WAGON during loading/unloading time to assist patrons.Jumping Pillow/Jump Pad* Yes No Size (# and/or feet x feet)* How many?* Manufacturer* Do you make separate charges for jumping pillows?* Yes No Please supply revenue breakout along with attendance:* Warning Signs and Safety Rules posted/printed on pillow surface:*Slide* Yes No How many?* Landing Surface* Grass Sand Gravel Dirt Liner Slide Length* 20 ft. 40 ft. 60 ft. 80 ft. Employee Attendant must be present at the top and bottom of ALL slides 60 ft. and longer.Slide Type* Open Closed Slide Type Comment Cow Train Ride* Yes No Wheel Base Requirements: Inside Wheel Base must be a minimum of 30". Outside Wheel Base must be a minimum of 39". All Kiddie Rides/Cow Trains must be pulled by limited speed capability vehicles or low horsepower tractors.Pumpkin Launcher* Yes No How many?* Pumpkin Patch?* Yes No Pedal Cars?* Yes No Pond* Yes No Water Activities ExcludedFenced In/Roped Off/Fishing* Fenced In Roped Off Fishing Size* Employee Attendant must be present at ALL times.Playground Equipment?* Yes No Please provide complete list of equipment:* Corn Canon* Yes No Camp Fires* Yes No Size of Fire Ring* Employee Attendant must be present at ALL times.How many?* What type of campfire?* Wood burning Propane Kiddie Zip/Handle Bar Slide* Yes No Maximum Weight Permitted is 100 lbs.Length* Height from Cable to Ground (ft.)* Type* Sitting Hanging/T-Bar Attendant Procedure for Starting and Landing of Kiddie Zip:*Employee Attendant must be present at ALL times.Offsite Parking?* Yes No Please provide location address:*Escape Room?* Yes No If yes, please complete supplementalPaintball Gallery?* Yes No If yes, please complete supplementalTrains?* Yes No Permanent track?* Max Speed* Amusement Rides?* Yes No Please provide a complete list of each ride*Please provide photos of all amusement rides* Drop files here or Select files Max. file size: 256 MB. Mechanical Bull?* Yes No Hay Bales / Hay Pyramid / Hay Mountain?* Yes No Pumpkin Swing?* Yes No Rock Wall?* Yes No Log Jam?* Yes No Inflatables?* Yes No Super Mega Slide?* Yes No How many?* Pony Rides?* Yes No Are ponies tethered?* Are pony rides covered elsewhere?* Is the applicant included as an additional insured on that policy?* Yes No Fireworks / Pyrotechnics?* Yes No Is applicant signing any Hold Harmless Agreement?* Yes No Please provide a complete copy of this agreement/contract* Drop files here or Select files Max. file size: 256 MB. Any other special events?* Yes No Please list dates and provide a description of the event:* If yes, please fill out the Special Events Supplemental App. **Employee attendance must be at each of the following at ALL times: campfire, hay ride, pond, kiddie zip - failure to follow these requirements could jeopardize coverage under your insurance policy.Please list and describe any other rides or attractions previously not mentioned:*Insurance Coverage will be written with limits of $1,000,000 per occurrence and an annual aggregate of $2,000,000. The Insured represents that the information contained in this application is accurate and that it shall be the basis of the policy of insurance. The Insured further represents that it has not withheld any information which would have affected the company’s decision to offer coverage. If the insured has withheld any such information with intent to defraud or give false information to the company, the Insured understands that its coverage may be voided. The Insured further understands that its failure to disclose any information in its possession, which may lead to a claim, will relieve the insurance company of any obligation under the policy.Additional InsuredsRelationship Name Address Relationship Name Address Relationship Name Address *SOME EXCLUSIONS INCLUDE, BUT ARE NOT LIMITED TO: PATRON TOUCHING, RAT RACERS / RAT ROLLERS, LIVESTOCK COVERAGE, ELECTRICAL SHOCK DEVICES, WATER ACTIVITIES.Insured Signature* Date* Electronic Signature Agreement* By checking this box I acknowledge that the information I have entered is accurate and understand that the field above constitutes as my electronic signature. Please review all the following fields to ensure your information is accurate. {all_fields}Section to be Completed by the Producer/Broker/AgentAgent Name Agent Signature Date CAPTCHA
