Type of Organization *

Corporation

LLC

Individual / Sole Proprietor

Partnership / Joint Venture

Not-for-Profit

Other

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Facility Address *

Please provide the physical location address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Person *

First Name

Last Name

Phone *

(###)

###

####

Are you currently insured?

Yes

No

Coverage Start Date *

MM

DD

YYYY

Do you Own or Rent your Facility?

Own

Rent

Does your Facility offer "Rage Room" activites *

Yes

No

Does your facility sell alcohol? *

Yes

No

Do you rent your facility for Private or Special Events?

Yes

No

Are there any amusement rides, air inflatable structures, rock climbing walls, etc. on premises or brought on premises temporarily? *

Yes

No

Is named insured involved in the sale or distribution of any products?

Yes

No

Are rules posted conspicuously and enforced at all times? *

Yes

No

Does your organization currently utilize a waiver system? *

Yes

No

Does your organization have a written safety plan or risk management plan in place? (For example: Emergency Procedures, Written/Posted Rules and/or Regulations, Code of Conduct, Consent Form, Emergency Contact Form) *

Yes

No

Are facility inspections and maintenance performed?

Yes

No

Are participants required to wear safety equipment during play?

Yes

No

Is the facility locked so that patrons cannot use it when closed? *

Yes

No

Has your past liability coverage been canceled in any way in the last three years? *

Yes

No

Is your current insurer non-renewing coverage? *

Yes

No

Have any liability claims been paid by your insurer during the last 3 years? *

Yes

No

The undersigned being authorized by and acting on behalf of the applicant and all persons or concerns seeking insurance, has read and understands this proposal and declares all statements set for herein are true, complete, and accurate. The undersigned further declares and represents that any occurrence or event taking place prior to the inception of the policy applied for which may render inaccurate, untrue, or incomplete any statement made herein will immediately be reported in writing to the insurer. The undersigned acknowledges and agrees that the submission and the insurer’s receipt of such report prior to the inception of the policy applied for is a condition precedent to coverage. It is understood and agreed that the completion of this application shall not be binding either to the Proposed Insured or to the Company until accepted by the Company or Companies. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly provides false information in an application for insurance may be guilty of a crime and may be subject to civil fines and criminal penalties. I certify that the above information is true and coverage is not applicable until accepted. *

Agree