Section 1: BUSINESS INFORMATION
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Bing
Customer Referral
Google
Manufacturer
Other
Postcard
Social Media
Trade Show
Yahoo
Company Name:
Business Name:
Contact Name:
FEIN/SS#:
DOB:
Address
Address/PO Box:
City:
State:
Zip code:
Phone Number:
Website:
Email:
Section 2: GENERAL INFORMATION
Requested Effective Date:
Date(s) of Event:
Time(s)
Name of Haunted House
Name of Facility
Location of Haunted House:
Description of Haunted House:
Has this Event been held in the past by the Applicant?
Yes
No
If yes, for how many years?
Estimated Attendance Per Day?
# of Tickets Printed?
# of Tickets Sold to Date?
Price of Admission?
Estimated Gross Receipts?
Estimated Total Payroll?
# of Employees & Volunteers
Total number of participants: 12 & younger
13-25
16-18
19 and older
What are the Limits of Liability Requested?
General Aggregate: $
Products Aggregate: $
Each Occurrence: $
Personal/Adv Injury: $
Fire Damage: $
Medical Payments: $
Is this Event Located Indoors or Outdoors?
Indoors
Outdoors
If Outdoors, Is the Area Fenced or Enclosed?
Yes
No
Please describe in detail all “Special Effects”
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Please make sure that you have completed everything to the best of your knowledge before going to the next page.
