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.
- Please send photos of all attractions present (including but not limited to hayrides, train rides, playgrounds, slides, jumping pillow, zipline, etc.)
- Please send photos of Agritourism signage posted.
- If horses are present, please send photos of Equine signage posted.
1. Describe your operations including a complete list of activities. Please attach a flier or provide website address if available.
2. Are operations year-round or seasonal?

Year-roundSeasonal
2a. If seasonal, what are your dates of operation.
3. How long have you been in business?
3a. If this is a new venture, what is your prior experience?
3. Are participants required to sign any releases of waivers? (If yes, please attach a copy of the waivers.)

YesNo
4. Do you have an operations/procedure manual?

YesNo
5. Do you have an employee training program?

YesNo
6. What is the minimum age requirement for your employees?
7. Are releases signed by all applicants? (Please attach a copy of the release.)

YesNo
8. Do you ever hire sub-contractors/independent contractors that carry their own insurance?

YesNo
8a. If yes, please describe:
8b. If yes, are certificates of insurance provided?

YesNo
8c. Do subcontractors name you as additional insured on their policy?

YesNo
8d. Total Cost ($)

9. Do you use any mobile equipment?

YesNo
9a. Check all that apply:

ATVsGolf CartsSnowmobilesBobcatsCranesTractorsHorse Drawn WagonHorse Drawn SleighsOther
9b. What is the use of this equipment? Check all that apply:

Transporting peopleOfficials/Staff OnlyTransporting Supplies or EquipmentOperated/Driven by PublicOther
9bi. Describe "Other":
9c. Where is the equipment stored when not in use?
9d. Who is responsible for the insurance of the mobile equipment?
10. What procedures are in place in the event of a medical emergency or injury?
11. Briefly describe what security measures will be taken. Include the number of security personnel and the name of the firm providing the security
12. Do you serve alcohol at your operation?

YesNo
12a.Liquor Sales (prior 12 months total receipts)
12b. List the name on the liquor license, type of liquor license and number:
12c. Has the applicant ever had their liquor licenses suspended or revoked?

YesNo
12d. If yes, please provide details:
12e. Has the applicant ever had any liquor liability losses?

YesNo
12f. If yes, please provide details:
12g. Will IDs be checked?

YesNo
12h. Have the servers of alcoholic beverages been through alcohol awareness server training?

YesNo
12i. Does the applicant allow BYOB on premises?

YesNo
12j. Do you allow anyone under the age of 18 to serve alcoholic beverages?

YesNo
12k. If yes: Who is providing the security in the area where the liquor is being served?
12l. Will you allow others to serve alcohol at this event? (If yes, Certificates of Insurance are required.)

YesNo
Note: If Liquor Liability coverage is desired, please contact Kevin Morency for a quote. (Liquor Liability will only be available if we provide the General Liability for your agritainment operation.)

ACTIVITIES AND AMENITIES OFFERED
1. Children’s Play Area, including homemade attractions

YesNo
1a. If yes, please describe attractions including dimensions, construction materials, landing area (e.g., corn pit, giant tire for climbing, haybale structures, obstacle course, giant slide, etc.):

2. Do you offer any of the following activities?

Rows	Yes	No
2a. Pedal Cars
2d. Stocked-Pond Fishing
2e. Bike Rental
2f. Greenhouses
2g. Climbing Wall

3. Do you offer apple, corn, pumpkin, watermelon cannons and/or slingshots

YesNo
3a. How far do the apples/pumpkins/corn cobs travel?
3b. Where is the activity in relation to all other attractions?
3c. Describe the landing area
3d. Is any parking located nearby?
4. Carnival Rides (Please note: Your policy will exclude amusement rides.)

YesNo
4a. If yes, please describe:
5. Do you sell any food or beverages, including concession stands?

YesNo
5a. Please list the type of cuisine served:
5b. Describe the cleaning and sanitation schedule:
5c. Are all cooking surfaces covered by a UL300 Extinguishing system?

YesNo
5ci. When was the date of last service?
5d. Is there a 40 BC fire extinguisher in the kitchen?

YesNo
5di. When was the date of last service?
5e. Do you serve or sell any meat/seafood products?

YesNo
5ei. If yes, do you have written procedures for proper handling, preparing, and serving of raw meat/seafood?

YesNo
5f. Has the local Department of Health inspected your operation? (If yes, provide a copy of the most recent inspection.)

YesNo
5g. Have you ever been cited for any health code violations?

YesNo
5gi. Briefly describe and provide copy of health code violations.
6. Do you manufacture or sell any products?

YesNo
6a. If yes, please list:
7. Do you allow food trucks to provide food and beverages at your operation?

YesNo
7a. If yes, please describe. Provide a copy of food truck license and health department inspection.
7b. If yes, do you obtain a certificate of insurance from the food vendor operation?

YesNo
8. Retail Operations on Site?

YesNo
8a. If yes, please describe:
9. Other (describe):

10. Please indicate gross sales for each segment of your operations:

Rows	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 - current year
Estimated Total Receipts for next 12 months

10a. Other (describe)
11. Location(s), Dates of Operation, Expected Attendance and Hours of Operation: (List additional locations on separate page)
Location 1: Address and Activities
Location 2: Address and Activities

11a. Please provide the following information about your locations.

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

CORN MAZE
1. Do you offer a corn maze?

YesNo
2. How big is the maze (in acres)?
3. Is the maze supervised?

YesNo
4. Do you have night mazes?

YesNo
5. Is the maze checked prior to closing?

YesNo
PONY RIDES
1. Do you offer pony rides?

YesNo
2. Are helmets required?

YesNo
3. Does the handler work alongside the horse and rider?

YesNo
HAY, SLEIGH, WAGON, OR BARREL / TRAIN RIDES
1. Do you offer any of the following activities? Please provide photo(s).

Hay ridesSleigh ridesTrain Rides (Barrel, Trackless, Railed)N/A

2. Describe the wagon(s)/sleigh(s)/train(s) used in the ride

Rows	Answer Below
a. Number owned
b. Number rented
c. Seating capacity
d. Age of hay/sleigh/wagon or barrel/train ride (years)
e. How fast does it travel? (mph)

e. Pulling unit:

TractorHorseGolf CartATV/UTVLawn TractorOther
ei. Other (describe):
f. Are rules and regulations clearly posted, including requiring riders to remain seated? (Please provide photo of safety signage - Example: "Stay Seated...No Standing Until Operator States Ride Has Stopped")

YesNo
g. Are you traveling on a designated route or set trail?

YesNo
h. Is there a maintenance/inspection program in place for vehicles/trains/wagons?

YesNo
hi. If yes, please describe program include how often each ride is checked:
i. Please describe the passenger loading/unloading procedure.
j. Are there any night rides?

YesNo
ji. If yes, what type of lights, etc. are used?
k. Describe the experience of the driver(s):
l. What type of training/orientation takes place?
m. In addition to the driver, how many employees are used for each wagon for supervision?
n. Is there any driving on or crossing of public roads?

YesNo
o. Do you maintain a safety log?

YesNo

PETTING ZOO
1. Do you offer a petting zoo to the public? (If Yes, please answer the following questions.)

YesNo
1a. Please list animal and number of each:
1b. Is there an experienced handler always supervising the petting zoo?

YesNo
1bi. What is the handler’s experience with the animals?
1c. Have all animals been properly vaccinated?

YesNo
1d. Do you have emergency procedures and equipment on site for animal bite? (First aid kit available.)

YesNo
1e. Do you have a safety precaution sign at the entrance? (Please provide picture of sign.)

YesNo
1f. Is the petting zoo area fenced? (two fences needed – outer fence may be snow or construction fence)

YesNo
1g. Do you allow visitors to feed animals? (Dry feed only) If yes, provide picture of "Don't eat animal feed" sign by feeding station.

YesNo
1gi. Please list animals that are allowed to be fed:
1h. Do you have a hand sanitizing station with a sign requiring people to sanitize their hands after petting the animals? (Please provide picture of sign.)

YesNo
PICK-YOUR-OWN OPERATIONS
(See separate sections for Pumpkins and Christmas Trees, if applicable.)
Note: Pick-Your-Own coverage will only be available if we provide the General Liability for your agritourism operation.
1. Do you offer u-pick operations to the public? (If Yes, please answer the following questions.)

YesNo
1a. List items you offer in public u-pick operations.
1b. Are these items grown at location(s) listed on page 2, Question 4?

YesNo
1b. If no (or obtain additional items from other sources), please provide list of items, vendor(s) and Certificate(s) of Insurance.
1c. Do customers use ladders or elevated platforms?

YesNo
PUMPKIN FARM TOURS AND SALES
1. Do you offer pumpkin farm visits and sales? (If Yes, please answer the following questions.)

YesNo
1a. Are these items grown at location(s) listed on page 2, Question 4?

YesNo
1a. If no (or obtain additional pumpkins from other sources), please provide list of items, vendor(s) and Certificate(s) of Insurance.
1b. Please provide a detailed description of the tour of your operation.
CHRISTMAS TREE SALES
1. Do you offer Christmas trees for sale? (If Yes, please answer the following questions.)

YesNo
1a. Are these items grown at location(s) listed on page 2, Question 4?

YesNo
1a. If no (or obtain additional trees from other sources), please provide list of items, vendor(s) and Certificate(s) of Insurance.
1b. Are customers allowed to cut or trim trees?

YesNo
1c. If yes, tools provided to cut trees-check all that apply:

Hand SawsPower SawsHatchet or AxeOther
1d. Do you load trees on/in customer vehicles?

YesNo
1e. Check if applicable:

Sledding/Tubing HillIce SkatingSkiingOther

INFLATABLES (Jumping Pillows, Bouncy Houses/Slides, Etc.)
1. Do you offer inflatables? (If Yes, please answer the following questions.)

YesNo

1a. Please complete table:

Rows	Amount
Receipts ($)
Number of Units
Number of Attendants

1b. Has the proposed coverage been purchased before?

YesNo
1b. If yes, Current Carrier
1b. If yes, Limit of Liability ($)
1c. Describe any losses or incidents in past three years:
1d. Are all inflatables properly anchored/secured/tied down?

YesNo
1e. Type of flooring in inflatables area)
1f. Do inflatables have signs clearly indicating age, height, size, capacity requirements?

YesNo
1g. Are all inflatables manned by an operator/attendant?

YesNo
1h. Are your inflatables inspected by the state and/or your employees?

YesNo

1i. Equipment Inspection

Rows	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?

1j. Renting Inflatables

Rows	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?

1k. Please complete chart below or provide a separate schedule with the following information:

Rows	Manufacturer	Type of Inflatable, Slide	Age/Height	Attraction Dimension	Capacity (Max)	Height of side
Item 1
Item 2
Item 3
Item 4

JUMPING PILLOW
1. Do you offer a jumping pillow? (If Yes, please answer the following questions.)

YesNo
1a. Describe the surface surrounding the jumping pillow:
1b. Is signage posted noting the rules and age requirements?

YesNo
1c. Is this activity supervised?

YesNo
HAUNTED HOUSE
1. Do you offer a haunted house? (If Yes, please answer the following questions.)

YesNo
1a. The haunted house is:

InsideOutside

Please answer the following questions:

Rows	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?

1n. If yes to any of above questions, please explain:

Please complete table:

Rows	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 during the entire event:
1s. Estimated gross receipts:
1t. Price of admission:

1u. Any special handling of young children?

YesNo
1v. Do you use lead or follow-up guides?

YesNo
1w. Door monitors?

YesNo
1x. Are exit signs clearly marked and illuminated?

YesNo
1y. If transportation is used to move attendees to the house, please explain the type of transportation, the distance they will travel, and how it is powered:
1z. Type of building:
1aa. Usual use:
1bb. Number of stories:
1cc. Age of building:
1dd. Square footage of building open to the public:
1ee. What type of divisions/walls?
1ff. Describe lighting on stairs:
1gg. If private security is used, how many guards?

N/AHow many guards?

ZIP LINE OPERATIONS
1. Do you offer a zip line? (If Yes, please answer the following questions.)

YesNo
2. Who designed the course?
2a. Were Certificates of Insurance obtained?

YesNo
3. Who constructed the course?
4. What year was the course originally built?
4a. How many zip lines does the course consist of?
4b. What is the maximum height of the course?
4c. What is the length of the course?
4d. How long does the ride last?
4e. Does the course contain any suspended bridges?

YesNoHow many?
4f. Are any portable elements used (i.e. challenge walls, etc.) or unique obstacles?

YesNo
5. Have you made any additions or alterations to the course since it was built?

YesNo
5a. If yes, list date of change, type of alteration (or element added), and construction vendor name:
6. How often is the course inspected?

DailyMonthlyAnnuallyOther
6a. Who inspects course?
6b. Date of last course inspection (month/year)
6c. Do you maintain a written log documenting inspections and related equipment?

YesNo
6d. Have you made recommended improvements to course since last inspection?

YesNoN/A
6e. Do you perform daily visual inspections of the course and equipment?

YesNo

Please answer the following:

Rows	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?

8. Are all participants required to wear gloves and helmets?

YesNo
9. Are participants harnessed prior to advancing to the top of the zip line platform?

YesNo
10. Does your course require participants to hand brake?

YesNo
10a. If yes, please describe instructions given to participants:
10b. If no instruction given, what method is used to stop participant?
11. Is the course rented to outside groups or individuals? (If yes, please provide copy of rental contract.)

YesNo
11a. If yes, do you provide supervision?

YesNo
11b. Gross receipts from leased periods:
12. Do you require all participants to sign a waiver of liability? (If yes, please attach a copy.)

YesNo
12a. If yes, do all minors have their parents or guardians sign their forms?

YesNo

MINIATURE GOLF
1. Do you offer miniature golf? (If Yes, please answer the following questions.)

YesNo

2. Please answer the following:

Rows	Receipts	Number of Attendants	Total Number of Holes	Number of Courses
Enter info:

3. Do fountains and waterfalls have ground fault interrupters in place?

YesNo
4. Is appropriate safety warning and rule/regulation signs posted at club rental counter and/or hole #1?

YesNo
GOLF DRIVING RANGE
1. Do you offer a golf range? (If Yes, please answer the following questions.)

YesNo
2. Receipts:
2a. Number of Stalls/Tee Boxes:
3. Are there partitions between stalls/tee boxes?

YesNo
3a. Describe partitions between tee boxes.
4. Maximum one (1) person allowed per tee box?

YesNo
5. Are there any two-tier driving platforms? (If yes, please provide picture.)

YesNo
5a. If yes, describe barriers.
6. Are other attractions exposed to the range?

YesNo
6a. Explain:
7. Do all ranges face away from the public access areas?

YesNo
8. Is the range fenced in?

YesNo
9. Is there a safety zone of at least 30 feet between the range, parking lots, roads, etc.?

YesNo
WEDDINGS
1. Are weddings performed on your premises? (If Yes, please answer the following questions.)

YesNo

2. Please provide the following information:

Rows	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

PROPERTY INSURANCE
1. Do you need Building and/or Content Coverage?

YesNo

1a. If yes, please complete chart below or provide a separate property schedule with the following information:

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

2. Do you need Equipment Coverage?

YesNo
2a. If yes, total value to insure for?

Replacement CostActual CostTotal Value ($)

2b. If yes, please complete equipment schedule below or provide a separate equipment schedule with the following information:

Rows	Year	Make	Model	Value to Insure For ($)
Item 1
Item 2
Item 3

COMMERCIAL AUTOMOBILE INSURANCE
1. Does the business title any automobiles or other operating vehicles in the business name?

YesNo
2. Is insurance coverage needed for owned automobiles?

YesNo

2a. (If yes, complete chart below or provide a separate vehicle/fleet schedule with following info.)

Rows	Vehicle Make	Vehicle Model	Cost New ($)	Year
Vehicle 1
Vehicle 2
Vehicle 3

2b. If yes, limits desired:

Rows	Amount ($)
Limit of Liability
Comprehensive Deductible
Collision Deductible

3. Do any of the employees, owners or officers drive personally owned automobiles/other vehicles in the course of their work?

YesNo
3a. If yes, how many?
3b. Do you verify they have liability coverage?

YesNo
3c. Limits? ($)
UMBRELLA AND WORKERS' COMPENSATION INSURANCE
1. Do you need a Commercial Umbrella?

YesNo
1a. If yes, limit of liability needed? ($)
2. Do you need Workers Compensation? (If yes, please contact Kevin Morency.)

YesNo
SIGNATURE
The information I have provided is true and accurate to the best of my knowledge. I have not willfully concealed or misrepresented any material fact(s) or information. I understand completion of this questionnaire does not compel the company to provide coverage.
Signature
Or Enter Your Full Name as Signature:
Date:
Questions? 877-244-9090
Kevin Morency | kmorency@morencyinsurance.com

Morency & Associates Inc.
141 New Shackle Island Rd, Hendersonville, TN 37075
Fax: 615-452-6580

https://agritainmentinsurance.com/
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