Section 1: BUSINESS INFORMATION
How did you hear about us?
Choose One
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)
First date of setup:
Last date for take down:
Would you like coverage for the set up and take down?
Yes
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”
Create Password (this will allow you to access you application at a later time) :
Submit
Please make sure that you have completed everything to the best of your knowledge before going to the next page.
