AMUSEMENT-ENTERTAINMENT DEVICE INSURANCE - INTAKE FORM

DEVICE & ATTRACTION INSURANCE - INTAKE FORM

MECHANICAL BULLS, AXE THROWING, INFLATABLES, AND ALL OTHER AMUSEMENT DEVICES / ATTRACTIONS

DEVICE AND ATTRACTION INSURANCE - INTAKE FORM

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APPLICANT INFORMATION

Name of Applicant / Insured :

What is the Formation Type of this Business?

Name of Contact Person

Email Address

Phone Number (mobile preferred)

Have you talked to an AGENT / BROKER at KELLY INSURANCE GROUP?

YES

What's the name of the AGENT / BROKER?

ABOUT YOUR BUSINESS

Is this a New Business?

YES

What Year was this Business Started?

Has there been and Changes in Ownership or Management?

YES

How many Years has the Business been under New Management / Ownership?

Total ANNUAL REVENUE from ALL SOURCES

Have You had success getting Quotes from any other Agents/Brokers?

YES

KELLY INSURANCE GROUP is MY FIRST PHONE CALL

If possible, please list the Names of the Insurance Companies that have Provided Quotes

THERE ARE ONLY A HANDFUL OF CARRIERS AVAILABLE THAT ARE ABLE TO PROVIDE QUOTES FOR YOUR TYPE OF BUSINESS. BY INFORMING US OF THOSE CARRIERS YOU ALREADY HAVE QUOTES FROM, WE SAVE TIME BY NOT ASKING THOSE UNDERWRITERS TO PROVIDE QUOTES, WHICH SAVES SIGNIFICANT TIME IN OUR SEARCH FOR QUOTES FOR YOUR BUSINESS.

CURRENT INSURANCE INFORMATION

In there any Current Insurance in Place for Your Business?

YES

I'M BEING CANCELLED OR NON RENEWED BY MY CURRENT CARRIER

Please Explain Your current Insurance Situation

What's the Name of Your current Insurance Carrier?

PREVIOUS CLAIMS, VIOLATIONS, or INCIDENTS of INJURY

HAVE YOU HAD ANY CLAIMS, PENALTIES, or VIOLATIONS, WHETHER INSURED OR NOT, IN THE PAST 5 YEARS?

YES

Please Describe those situations here.

Has there been any INJURIES sustained as a result of Your Business Operations in the past 5 Years?

YES

Please Describe those INJURIES here...

MAILING ADDRESS INFORMATION

Street Address

City

State

Zip Code

LOCATION of OPERATIONS

Where is the DEVICE / ATTRACTION Operated? check all that apply

AT THE MAILING ADDRESS PREVIOUSLY INPUT

AT ANOTHER LONG-TERM or PERMANENT LOCATION or LOCATIONS

THE DEVICE / ATTRACTION IS MOVED FROM SITE to SITE

Location #1
ADDRESS	USE TYPE ENTER YOUR OWN USE TYPE (optional)

Is Your DEVICE / ATTRACTION ever Operated in Other States?

YES

What Other States?

MORE ABOUT YOUR OPERATION

Does Your OPERATION Include the USE OF... (check all that apply)

MECHANICAL BULLS

AXE THROWING

OTHER TYPES of DEVICES / ATTRACTIONS

Regarding the Consumption of ALCOHOL Around the DEVICE / ATTRACTION (select all that apply) :

LIQUOR / BEER IS CONSUMED ON SITE - SERVED BY OTHERS

LIQUOR / BEER IS CONSUMED ON SITE - SERVED BY US

LIQUOR / BEER IS NEVER CONSUMED or AVAILABLE ON SITE

WHAT COVERAGE TYPES ARE BEING REQUESTED (check all that apply)

GENERAL LIABILITY

WORKERS COMPENSATION

DEVICE / ATTRACTION PHYSICAL DAMAGE - OWNED

UMBRELLA / EXCESS LIABILITY

DEVICE / ATTRACTION PHYSICAL DAMAGE - RENTED

OTHER COVERAGES NOT LISTED HERE

LIQUOR LIABILITY

WHAT OTHER COVERAGES TYPES ARE BEING REQUESTED (check all that apply)

GROUP or INDIVIDUAL ACCIDENT

OFFICE TYPE PROPERTY (desks, computers, copiers, etc.)

CYBER / DATA BREACH LIABILITY

EMPLOYMENT PRACTICES LIABIILITY

FOREIGN LIABILITY

OWNED BUILDING COVERAGE

E & O

AUTOMOBILE LIABILITY - OWNED or NON OWNED

OTHER COVERAGES NOT LISTED HERE

Please List the OTHER Types of Coverages Being REQUESTED

DEVICE / ATTRACTION DETAILS

In Order to provide a Quote, we Need SPECIFIC DETAILS regarding each DEVICE / ATTRACTION Used in Your Business. You can ENTER this INFORMATION BELOW, or IF YOU HAVE THIS INFORMATION IN A SEPARATE DOCUMENT OR SPREADSHEET, YOU CAN UPLOAD IT ON THIS FORM.
WHAT WOULD YOU LIKE TO DO?

PLEASE SELECT BELOW

ENTER THE INFORMATION NOW

UPLOAD THE INFORMATION

DEVICE / ATTRACTION INFORMATION

FOR ALL MECHANICAL BULLS - MAKE, MODEL, & SERIAL NUMBER IS REQUIRED.
IF PROPERTY COVERAGE IS DESIRED, REPLACEMENT COST OF THE DEVICE/ATTRACTION IS REQUIRED.

Device / Attraction #1

DESCRIPTION or "TYPE" of DEVICE or ATTRACTION

MAKE of DEVICE / ATTRACTION

MODEL of DEVICE / ATTRACTION

YEAR BUILT or MANUFACTURED

SERIAL NUMBER

ANNUAL REVENUE GENERATED

REPLACEMENT VALUE

IS THIS DEVICE AT A FIXED SITE OR TRANSPORTED?

Fixed Site Transported

IS THIS DEVICE EVER LEFT UNATTENDED?

Yes No

OWNED OR RENTED?

Owned Rented

WHEN UPLOADING, IT'S IMPORTANT THE FOLLOWING ARE INCLUDED FOR EACH DEVICE / ATTRACTION : 1) DESCRIPTION or "TYPE" of DEVICE or ATTRACTION 2) MAKE of DEVICE / ATTRACTION 3) MODEL of DEVICE / ATTRACTION 4) YEAR BUILT or MANUFACTURED 5) SERIAL NUMBER 6) ANNUAL REVENUE GENERATED FROM DEVICE / ATTRACTION 7) REPLACEMENT VALUE 8) IS THIS DEVICE AT A FIXED SITE OR TRANSPORTED? 9) IS THIS DEVICE EVER LEFT UNATTENDED? 10) IS THE DEVICE / ATTRACTION OWNED or RENTED.
⭐ IF YOU NEED PHYSICAL DAMAGE COVERAGE FOR THE SPECIFIC DEVICE / ATTRACTION, REPLACEMENT VALUE IS REQUIRED. ⭐ FOR ALL MECHANICAL BULLS - MAKE, MODEL, & SERIAL NUMBER IS REQUIRED.

UPLOAD LIST OF ALL DEVICES / ATTRACTIONS USED

Max. file size: 16 MB.

INFORMATION ABOUT WORKERS & OPERATORS

What Types of Workers are Used in Your Business? (check all that apply)

OWNER or OWNERS OPERATE THE BUSINESS

EMPLOYEES ARE USED

SUB CONTRACTORS ARE USED

OWNER ACTIVITY SECTION

Owner Duties & Work Details

Enter each owner and their duties. You can add multiple owners, and multiple duties per owner.

Owner #1

OWNER NAME

DUTY AND WORK DETAIL

Does the OWNER have SAFETY CERTIFICATIONS? Or, memberships in Safety Organizations?

YES

Describe in Detail ALL SAFETY CERTIFICATIONS:

EMPLOYEE INFORMATION SECTION

Employee Types & Guesstimated Annual Payroll

Employee Type #1

EMPLOYEE TYPE

GUESSTIMATED ANNUAL PAYROLL FOR THIS TYPE ($)

Do any Employees have SAFETY CERTIFICATIONS?

Or, memberships in Safety Organizations?

YES

Describe in Detail ALL SAFETY CERTIFICATIONS:

SUBCONTRACTOR ACTIVITY SECTION

Subcontractor Types & Guesstimated Annual Cost

Please list each subcontractor type and the total annual cost for that type.

Subcontractor Type #1

SUBCONTRACTOR TYPE

GUESSTIMATED ANNUAL SUBCONTRACTOR COST FOR THIS TYPE ($)

Do any SUB CONTRACTORS have SAFETY CERTIFICATIONS? Or, memberships in Safety Organizations?

YES

Describe in Detail ALL SAFETY CERTIFICATIONS held by SUB CONTRACTORS:

MORE ABOUT THE OPERATORS

NUMBER OF OPERATORS SUPERVISING AT ANY ONE TIME:

PLEASE INPUT THE FULL NAME OF EACH OPERATOR ALONG WITH AGE VERIFICATION

NAME OF DEVICE OPERATOR

OVER THE AGE OF 18?

Yes No

ARE RIDE OPERATORS TRAINED TO STRICTLY ENFORCE ALL RULES / REGULATIONS EVEN IF IT MEANS STOPPING A RIDE EARLY OR REFUSING A RIDE TO A CUSTOMER:

YES

CHECK ALL that Apply Regarding the DEVICE / ATTRACTION while ON-SITE & NOT IN USE

LEFT UNATTENDED OVERNIGHT

OCCASIONALLY LEFT UNATTENDED DURING AN EVENT

UNATTENDED WHILE BEING SET-UP (someone else sets it up without you there)

EVENTS REQUIRE SOMEONE ELSE TO MONITOR EQUIPMENT

'FREE' USES or FREE RIDES ARE GIVEN

Please describe How & Why DEVICES / ATTRACTIONS are left UNATTENDED

Please Describe the Situations that REQUIRE SOMEONE ELSE TO MONITOR EQUIPMENT

Please Describe how 'FREE' Rides / Uses are Given and When

CHECK ALL APPLICABLE REGARDING DEVICE / ATTRACTION OPERATORS MANUAL :

DESCRIBES PROPER OPERATION OF EQUIPMENT

ROUTINE INSPECTION OVERVIEW IS INCLUDED

REQUIRED MAINTENANCE PROTOCOLS

TESTING PROCEDURES OVERVIEW

PRODUCT WEAR DESCRIPTIONS

NO AVAILABLE OPERATORS / MANUFACTURER MANUALS

DESCRIBE HOW SAFETY PRECAUTIONS / INSPECTIONS WILL BE FOLLOWED WITH NO AVAILABLE OPERATORS / MANUFACTURER MANUALS

Please Describe how the DEVICES / ATTRACTIONS are INPSECTED & WHEN

Name of Person Responsible for INSPECTION the DEVICES / ATTRACTIONS

What is the MINIMUM Age of RIDERS or USERS?

Does this DEVICE / ATTRACTION have any WEIGHT REQUIREMENTS?

YES

Please describe WEIGHT Requirements Here :

PARTICIPANT LIABILITY SECTION

Check ALL that Apply regarding How You Deal with USERS & RIDERS

PARTICIPANT WARNINGS POSTED IN A CONSPICUOUS PLACE FOR ALL PARTICIPANTS TO REVIEW (IN ENGLISH & SPANISH)

PARTICIPANTS OVER 18 YEARS OLD REQUIRED TO SIGN A WAIVER OF LIABILITY

PARENTS/LEGAL GUARDIANS REQUIRED TO SIGN A WAIVER OF LIABILITY BEFORE CHILDREN USE DEVICE / ATTRACTION

OPERATOR CHECK PHOTO ID TO VERIFY THE AGE OF THE PARTICIPANT

PARTICIPANTS ARE MADE AWARE THEY ARE USING EQUIPMENT / RIDING AT THEIR OWN RISK

THE ENTERTAINMENT / RIDE OPERATOR ASKS PARTICIPANTS IF THEY HAVE ANY PRE-EXITING CONDITIONS

PARTICIPANTS ARE AWARE THAT THEY MAY REQUEST THE RIDE(S) TO BE STOPPED AT ANY TIME

THE ENTERTAINMENT OPERATOR CHECKS PHOTO ID TO VERIFY PARTICIPANT AGE

PARTICIPANT WAIVERS ARE SIGNED IN THE PRESENCE OF THE OPERATOR / ATTENDING EMPLOYEE

Where are the DEVICES / ATTRACTIONS Used?

INDOORS

OUTDOORS

BOTH

DESCRIBE YOUR PROCESS FOR MONITORING THE WEATHER AND PLACING A STOP TO RIDES DUE TO INCLEMENT WEATHER

LIQUOR CONSUMPTION PRACTICES

WHAT ARE YOUR PROCEDURES FOR SERVING ALCOHOL / HAVING ALCOHOL ON PREMISES

WHAT IS YOUR PROCEDURE FOR HANDLING AN INTOXICATED INDIVIDUAL

Check ALL that Apply

STAFF / EMPLOYEES / SUBCONTRACTORS ARE TRAINED TO SERVE ALCOHOL

ALCOHOL IS SERVED DURING or PRIOR TO DEVICE / ATTRACTION USE

STAFF / EMPLOYEES / SUBCONTRACTORS NEVER SERVE ALCOHOL

Regarding DEVICE / ATTRACTION use for GROUPS, please Describe those Procedures :

ie BACHELOR / BACHELORETTE PARTIES, BIRTHDAY PARTIES, etc...

Are You RESPONSIBLE for Providing any SECURITY?

YES

DO YOU EVER ENTER INTO ANY AGREEMENTS WITH POLICE, MUNICIPALITIES OR PRIVATE VENDORS WHERE SECURITY IS PROVIDED:

YES

WHAT ARE YOUR HOURS OF OPERATION?

Are there ANY SECURITY CAMERAS in PLACE?

YES

SOMETIMES

IF YES, ARE THE VIDEOS HELD ON FILE FOR A MINIMUN OF 30 DAYS?

YES

Please explain how VIDEOS are STORED & KEPT

MECHANICAL BULL SECTION

Please Check All that Apply regarding the USE of MECHANICAL BULLS

THE BULL IS ELECTRIC

EACH BULL HAS AN EMERGENCY SHUT OFF

EACH BULL IS EQUIPPED WITH VARIABLE SPEED CONTROLS

EACH BULL HAS SOFT HORNS

THE BULL HAS A PADDED HEAD

THERE IS A MINIMUM FENCED RADIUS OF 10 FEET AROUND THE BULL

THE BULL HAS ENCLOSED INFLATABLE ARENA WITH A MINIMUM OF 16 INCH INFLATABLE LANDING

THERE IS A MINIMUM CEILING CLEARANCE OF 12 FEET OVERHEAD OF THE BULL

THE BASE UNIT IS COMPLETELY COVERED WITH PADDING

LIST OF VENUES WHERE THE RIDE WILL BE OPERATED

CHECK ALL THAT APPLY

BARS / TAVERNS

PRIVATE PARTIES

RODEOS

CARNIVALS or FAIRS

MECHANICAL BULL RIDING COMPETITIONS

OTHER

Please Describe the 'OTHER' Option SELECTED ABOVE

Have You already listed the BAR / TAVERN Location Address earlier in this Form?

YES

What's the Address of the BAR / TAVERN?

CUSTOMER WAIVER REQUIREMENT

I WILL COLLECT A WAIVER FOR EVERY RIDER AND SAVE
PERMANENTLY

I AGREE

AXE THROWING SECTION

Select ALL that APPLY regarding AXE THROWING ATTRACTIONS

THERE ARE SEPERATE AISLES / LANES IN THE PREMISE AND PARTICIPANTS WILL BE UNABLE TO MOVE BETWEEN TARGETS AND THROWERS:

NO DROP OFF AND PICK UP OF MINORS (UNDER 18 YEARS OF AGE)

LIVE MUSIC IS PLAYED

ALCOHOL IS SERVED

ARMED SECURITY IS PRESENT

WHAT PERCENTAGE OF REVENUE IS FROM ALCOHOL SALES

ARE ALL STAFF / WORKERS TIPS TRAINED AND LICENSED SERVERS?

YES

NOT APPLICABLE, NOT RESPONSIBLE FOR ALCOHOL SALES / SERVING

DRINK LIMIT IS ONE PRIOR TO AXE THROWING AND NO MORE THAN TWO DRINKS PER HOUR

YES

3 DRINKS MAX ARE ALLOWED DURING VISIT

YES

Would You like a LIQUOR LIABILITY Quote?

IF YES, WE MAY NEED A COPY OF YOUR LIQUOR LICENSE. WE CAN DISCUSS ONCE YOU SUBMIT THIS FORM.

YES

FINAL UNDERWRITING QUESTIONS & REQUIREMENTS

Most of our UNDERWRITERS require 'LOSS RUNS' in order to Quote. These may not be Required, but You should discuss this possibility with Us. Do you have copies of Loss Runs?

NOT YET

WAITING ON 'LOSS RUNS' FROM MY OTHER AGENT / BROKER

I HAVE THE 'LOSS RUNS'

UPLOAD LOSS RUNS HERE

Max. file size: 16 MB.

Open Statement of No Known Losses Form (New Tab)

By checking this box, I acknowledge that, to the best of my knowledge,
there are NO KNOWN LOSSES for the coverage(s) being requested.

DISCLAIMER(Required)

SUBMITTING THIS FORM DOES NOT PROMISE COVERAGE, NOR IS BINDING IN ANY WAY. THE PURPOSE OF THIS FORM IS TO ONLY GATHER PERTINENT INFORMATION IN A CLEAR & TRANSPARENT PROCESS - IN ORDER THAT WE MAY SEARCH FOR QUOTES FOR YOU.
By submitting this form, you are allowing us to use this information only for the purposes of getting you insurance quotes and communicating with you via email/phone/or text.
By signing below, you understand the above statements and also promise that the information gathered in this entire form is correct and accurate; or includes guesstimates including projections that are correct to the best of your knowledge.

I UNDERSTAND

SIGNATURE: