Agritainment Insurance Questionnaire

Agritainment Insurance Questionnaire
Applicant's Name:*
Address:*
Mailing Address
Address (cont):*
Mailing Address - continued
Contact:*
Email*
Telephone:*
Website
Fax:
Applicant is:

IndividualPartnershipCorporationOther (specify)Other
Current Carrier:
Expiration Date:
Limits: ($)
Premium: ($)
Deductible: ($)
Limit of Liability Desired:

$300,000$500,000$1,000,000
GENERAL INFORMATION - Please complete all questions in this section.
1. Describe your operations including a complete list of activities. Please attach a flier or provide website address if available.
2. Do you offer any of the following activities?

Yes No
2a. Hay Rides
2b. Sleigh Rides
2c. Pony Rides
2d. Amusement Devices

YesNo
2d. If yes, please describe:
2e. Do you operate a restaurant?

YesNo
2e. If yes, please describe:
2f. Do you manufacture food?

YesNo
2f. If yes, please describe:
2g. Food Sales?

YesNo
2g. If yes, please describe:
2h. Retail Operations on Site?

YesNo
2h. If yes, please describe:
2i. Other (describe):
3. Do you ever hire sub-contractors/independent contractors that carry their own insurance?

YesNo
3a. If yes, please describe:
3b. If yes, are certificates of insurance provided?

YesNo
3c. Do subcontractors name you as additional insured on their policy?

YesNo
3d. Total Cost ($)

	Amount ($)
Admission Fees
Rides (Fees in addition to admission, such as: Pony Rides, Jumping Pillows, Trains, etc.)
Pumpkin Sales
Christmas Tree Sales
Pick-Your-Own Sales
Restaurant/Concession Sales on Site
Food Sales on Site
Retail Sales on Site
Liquor Sales
Other (Describe below)
TOTAL SALES

	Acreage	Own or Lease	Dates Open	Expected Daily Attendance	Hours of Operation
Location 1
Location 2

	Yes	No
1i. Is the equipment inspected after each use?
If yes, a) Are inspection records maintained?
If yes, b) Are time period inspection records kept?

	Yes	No
1j. Do you rent inflatables? (If yes, attach a copy of the rental agreement)
If yes, a) Are they rented with operators/attendants?
If yes, b) Do you deliver the inflatables?
If yes, c) Do you set up the inflatables?
If yes, d) Do you tear down inflatables?
If yes, e) Do you use the manufacturer’s checklist for the set up and use of the equipment?
If yes, f) When used outdoors, are there procedures to suspend use during inclement weather?
If yes, g) Does Rental Agreement have a Hold Harmless Clause?

	Yes	No
1b. If outdoors, is the area fenced?
1c. Are any candles used?
1d. Is there any human contact?
1e. Is there any use of live animals?
1f. Are there any moving floors, walls or steps?
1g. Are there any slides?
1h. Are bleachers or platforms used?
1i. Are smoke effects used?
1j. Are extension cords used?
1k. Is the haunted house inspected by the fire department prior to use?
1l. Are there age restrictions/limits?
1m. Is first aid available?

	Enter info below
1o. Maximum number of individuals in house at one time:
1p. Number of days open:
1q. Hours of operations:
1r. Anticipated number of people to go through the haunted house:
1s. Estimated gross receipts:
1t. Price of admission:

	Enter info below
7. Total number of participants anticipated in coming year:
a. Anticipated receipts:
b. Percentage of Participants - under 18 years old
c. Percentage of Participants - over 18 years old
d. Minimum Age:
e. Maximum Age:
f. Minimum Weight:
g. Maximum Weight:
h. How are weight requirements checked/enforced?

	Enter info below
2. How many weddings per year?
2a. Maximum number of guests
3. Are receptions held on site?
3a. Number of receptions per year

	Building Age	Building Construction	Building Limit ($)	Content Limit ($)
Building 1
Building 2