Insured By the CIA - Cossio Insurance Agency

INFLATABLE DEVICE APPLICATION

Proposed Effective date(mm/dd/yyyy):  

PLEASE COMPLETE EACH LINE ON FORM

Corporate Name
Business Name

Type of Business: Check One

Individual Partnership Corporation


Contact Name E-mail Address


Business phone  Fax  Cell 


Do you have a website? Yes No website address:


Mailing Address:
Street City State Zip

Location/storage Address: If different from Mailing Address

Street City State Zip


Federal Employee ID# Year Business Started 

Detailed description of operations:


Do you currently have a general liability policy (s)?
Yes
No
Current/Previous Insurance Carrier:   Policy Number:  
Expiring premium:   $ Dates of policy period (mm/dd/yy): to
Please provide us with the Declarations page and claim history for the past 3 years.


Any claims?  Yes   No Please explain any claims:
Any policy declined, cancelled or non-renewed?
Yes     No  

City Limits: Inside Outside
Property: Owned Leased/Rented Other

Name & Address of Lessor/Landlord
Name
Address
Address
City
State
Zip

Name & Address of Additional Insured
Name
Address
Address
City
State
Zip

Total Estimated Annual Gross Receipts $

***If property coverage is desired then please complete Property Section***

Recreational Equipment Liability Application

1. Is this an off-premise rental business? Yes No
  If no, describe:
2. Is this a new business? Yes No
3. Detailed description of business activities:
   
4. Years experience in industry:
 
5. Any training or certifications? Yes No
  Explain:
6. Do you provide instruction? Yes No
  Explain
7. Does the applicant have any animal rides or animal exposures?
Yes
No
  If yes please describe:
8. For amusement rides, describe the height and type of fencing required for spectator safety:
   
9. Do units/rides have signs marking age, height, and size limitations?
   
Yes
No
  Please explain limitations:
       
10. Are all units/rides inspected?
Yes
No
  If yes , please provide details of the Inspection process , including who completes inspection, frequency of inspection and if inspection /maintenance logs are maintained:
   
   
       
11. Please describe the nature of the adult supervision provided while any ride or device is in use:
   
       
12. Do you set up own devices?
Yes
No
       
13. Do you stay in attendance while in operation?
Yes
No
  If no, is a waiver/release of liability used?
Yes
No
       
14. List states in which applicant operates:
       
15. Total number of employees:
16. Are employees leased?
Yes
No
17.  Annual payroll: $
18. Do you have a training program?
Yes
No


Inventory Listing:
It is very important that a complete listing of rides and/or devices be included with your application.

Name and/or Type of Amusement Device or Ride

Age

Manufacturer

Dimensions

Serial Numbers

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If you have an inflatable or portable climbing wall, a climbing wall application must be completed .


If this is a rental business, it is a condition of coverage that a copy of rental agreement and/or release of liability form be submitted with this application. No coverage will be provided unless this condition is met .


Any person who knowingly and with intent to defraud any insurance company or other person, files an application for Insurance containing any false information or conceals information concerning any fact material thereto, for the purpose of misleading, commits a fraudulent insurance act, which is a crime.  Please acknowledge that the information provided is accurate, to the best of your knowledge, by typing your name in the box below: