Trampoline

1

Email

example@example.com

2

Does facility comply with ADA Requirements?

Yes

No

3

Size of facility: Square Footage: Indoor

4

Size of facility: Square Footage: Outdoor

5

Size of facility: Square Footage: Acreage

6

Number of years in business

7

Number of years under current management

8

Have you used any Amusement Facility Consultant?

Yes

No

9

If yes, who?

10

Proposed Effective Date

Date

11

Expiration Date

Date

12

Prior Insurance Carrier

13

Has insurance ever been canceled?

Yes

No

14

What is your expiring premium for General Liability?

15

Excess?

16

Limits requested?

17

What associations do you belong to?

18

Hours of operation:

19

Operating Season:

20

Are you aware of any circumstances that may result in a claim made against you?

Yes

No

21

If yes, please describe:

22

Do you own or lease premises?

23

Other occupancies

24

Describe parking facilities - location, lighted, sloped, etc.

25

Describe type of security (armed/unarmed) for parking, facility, etc.

26

If hired security, is Certificate of Insurance provided naming you as an additional insured?

Yes

No

27

If security is in-house, what type of training is provided?

28

Is Assumption of Risk signage present?

Yes

No

29

If yes, describe type, location and provide photos:

30

Are waivers signed for any of the attractions?

Yes

No

31

If yes, which attractions?

32

Number of surveillance cameras: Inside

33

Number of surveillance cameras: Outside

34

Number of surveillance cameras: Total

35

Type of surveillance system:

36

How long is video stored?

37

Does surveillance capture all elements in the facility including waiver signing?

Yes

No

38

Number of employees certified in CPR & First Aid

39

Is there at least one employee, certified in CPR and First Aid, present at all times?

Yes

No

40

Describe medical facilities provided:

41

Describe how injuries and medical emergencies are handled and by whom?

42

Are there any employed nurses or physicians?

Yes

No

43

Are there any programs that allow overnight stays?

Yes

No

44

If yes, describe

45

Any operations sold, acquired or discontinued in the last 5 years?

Yes

No

46

Any storage, disposing, discharging or transporting of hazardous materials?

Yes

No

47

If yes, describe:

48

Do ALL Attractions, Equipment and Fencing meet ASTM standards?

Yes

No

49

Do you sponsor any sporting, competitions or social events?

Yes

No

50

If yes, explain:

51

Do you host any special and/or live events?

Yes

No

52

If yes, describe:

53

Do you have any interest in Active Shooter coverage?

Yes

No

54

ATTRACTION INFORMATION: GROSS ANNUAL RECEIPTS (Current and Next Year Estimated) Total Gross Receipts

55

ATTRACTION INFORMATION: GROSS ANNUAL RECEIPTS (Current and Next Year Estimated) Average Annual # of Attendance

57

PLEASE NOTE: Our policy is a “scheduled” policy meaning that all attractions to be covered under the policy must be listed on our policy. Please list/provide any other attractions not listed above:

58

TRAMPOLINES

Yes

No

59

Who is the manufacturer?

60

Who installed the trampolines?

61

Who provides maintenance of trampolines/facility?

62

How often are the trampolines inspected?

63

What is the distance from floor to trampoline?

64

Ratio of monitors to participants:

65

Is there redundant netting under all jump surfaces?

Yes

No

66

Is barrier netting at the top of all platform barriers?

Yes

No

67

Are there any hanging apparatus from the ceiling in the jumping area?

Yes

No

68

If yes, what is the distance from apparatus to jumping area?

69

Describe signage for rules/assumption of risk:

70

Who developed/designed the content of the Assumption of Risk signage?

71

Describe the formal employee training program (e.g. length of training, rules, monitoring, incident reports, etc.):

72

Do trampolines meet ASTM standards (NFP701, ASTM F1159, F2370 & F2375)?

Yes

No

73

Is the Insured a member of IATP (International Association of Trampoline Parks)?

Yes

No

74

Are parents or legal guardians required to sign waivers on behalf of all minors?

Yes

No

75

Is there a formal incident reporting and follow-up procedure in place?

Yes

No

76

If yes, please describe:

77

Have any of the attractions been modified from manufacturer specifications?

Yes

No

78

If yes, please explain:

79

What is the minimum age of participants?

80

Are participants separated by age and/or jumping experience?

Yes

No

81

If yes, describe how it is controlled:

82

Are any classes or lessons provided (e.g. jump or fitness instruction)?

Yes

No

83

If yes, please describe:

84

Are competitive jump lessons taught?

Yes

No

85

Are there performance trampolines?

Yes

No

86

Is there a “stunt jump?”

Yes

No

87

Do you keep a log of all maintenance?

Yes

No

88

Do you provide “low light jumping,” “glow,” or “cosmic jumping?”

Yes

No

89

If yes, do you prevent participants from flipping in low light conditions?

Yes

No

90

Do you allow people to jump who are not paying customers and who have not signed a waiver and been provided rules of participation?

Yes

No

91

Describe any elements or devices not listed on this application (such as Mechanical Bull, Wipe Out, Meltdown, Trapeze, Battle Beam, and/or SlackLine):

92

ROCK CLIMBING

Yes

No

93

Who is the manufacturer?

94

Who installed Walls?

95

Are participants allowed to climb on their own?

Yes

No

96

Number of walls

97

What is the height of the Bouldering/Traversing wall ft.?

98

Are spotters required?

Yes

No

99

How are participants checked in?

100

Does rock wall meet all CWIG (Climbing Wall Industry Group) standards?

Yes

No

101

What type of safety equipment is used?

102

Describe the belay system:

103

Describe Safety Inspection policy for wall, hardware, equipment and rental gear:

104

Who is responsible for maintenance inspections?

105

How often are inspections done?

106

Describe employee training procedures?

107

What type of assumption of risk signs (indicating age, size, height, rules, etc.)?

108

Type of instructions given:

109

Describe landing surface – thickness, makeup, extent of fall protection:

110

How many attendants are stationed at each rock wall?

111

NINJA COURSE

Yes

No

112

Who is the manufacturer?

113

Ratio of monitors to participants:

114

Is a monitor present at all times?

Yes

No

115

Minimum age:

116

Minimum height:

117

Maximum number of participants:

118

Square footage of course:

119

Type of instructions given:

120

Describe Rules/Warnings/Assumption of Risk signage:

121

Is there a Salmon Ladder obstacle?

Yes

No

122

Is there a Warp Wall obstacle?

Yes

No

123

List the different type of obstacles/elements:

124

Is the course:

125

Describe padding and safety netting system below the obstacles:

126

Is the course separated into child and adult level of difficulty?

Yes

No

127

Do you repair OR modify equipment?

Yes

No

128

If yes, describe modifications:

129

How often do you inspect equipment?

130

Is there a maintenance log kept?

Yes

No

131

Are surveillance cameras able to see all elements of the course?

Yes

No

132

INFLATABLES

Yes

No

133

Who is the manufacturer?

134

Number of inflatables

135

Number of inflatables off premises:

136

Number of indoor inflatables:

137

Type of flooring in inflatable area:

138

Number of outdoor inflatables:

139

How are they anchored/secured/tied down?:

140

Describe each inflatable:

141

Who is responsible for inspections?

142

How often are inflatables inspected?

143

Is each inflatable manned by an attendant/operator?

Yes

No

144

Describe training:

145

Describe signage:

146

Describe controls to prevent double bouncing and when participants with different sizes/abilities are grouped together:

147

Type of instructions given:

148

ARCADES

Yes

No

149

Number of machines

150

Any coin-operated rides?

Yes

No

151

If yes, how many?

152

Any ride simulators or interactive games?

Yes

No

153

If yes, describe and list:

154

Are machines grounded properly?

Yes

No

155

Are machines owned or leased?

156

If leased, provide agreement.

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157

Who provides maintenance/service on machines?

158

How many attendants are present in arcade area?

159

RESTAURANT/SNACK BAR

Yes

No

160

Restaurant exposure:

161

Square foot? ft.

162

Is food area lease/subcontracted out?

Yes

No

163

If leased, does insured receive COI from sub contractor listing them as an additional insured?

Yes

No

164

If yes, provide contract.

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165

Are alcoholic beverages sold on premises (e.g. beer, wine, liquor)?

Yes

No

166

Are portable fire extinguishers provided in kitchen?

Yes

No

167

Who is responsible for cleaning hoods and ducts?

168

How often?

169

Are cleaning records kept?

Yes

No

170

Number of each: Deep Fryers:

171

Number of each: Ovens:

172

Number of each: Grills:

173

Number of each: Broilers:

174

Number of each: Ranges:

175

Describe maintenance/inspections procedures:

176

Have there been any issues with State Inspections?

Yes

No

177

If yes, explain:

178

CHILD CARE/CHILD DROP-OFF/LOCK-INS

Yes

No

179

What is the maximum number of children dropped off/left in your care at one time?

180

What is the ratio of monitors to children left in your care?

181

What is the minimum age of a child left in your care?

182

What are the maximum hours per day that a child may be in your care?

183

What type of system do you have in place for checking in/out children when they arrive and depart?

184

Do you have written training/safety procedures including performing background checks on employees or volunteers in charge of drop-off service?

Yes

No

185

If yes, provide a copy.

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186

Briefly describe the programs you offer for children to be dropped off and supervised by employees:

187

Type a question