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• Section 1: POLICY RECOMMENDATIONS
• (Please check any you are interested in)
• General Liability
• Accident Medical
• Earthquake
• Inland Marine
• Worker's Compensation
• Commercial Auto
• EPLI
• Flood
• Hired & Non-Owned Auto
• Umbrella
• Abuse/Molestation
• Cyber Liability



• Section 1B: Submission Requirements
• 1) Resume (New Business Only)
• 2) Lease Agreement
• 3) Daily Safety Checklist
• 4) Diagram of premises
• 5) Equipment/Attractions List
• 6) Safety Rules
• 7) Waiver
• 8) Loss runs for last 5 yrs.
• 9) Business & Financial Plan (New Business Only)
• 10) Evacuation Diagram & Procedures



• Section 1C: Company Information
• How did you hear about us?     Choose One Bing Customer Referral Email Blast Google Manufacturer Other Postcard Social Media Trade Show Yahoo
• Business name:
• Name of facility:
• Contact first name:
• Last name:
• Phone number:
• Email address:
• Website:
• Date of Birth:
• FEIN/SS#:



Mailing Address

• Mailing address:
• City:
• State:
• Zip code:



Physical Address

• Physical address:
• City:
• State:
• Zip code:



• Business type?
  Corporation Partnership Individual Non-Profit Governmental Other
• If other, please describe:
• Year business was established:
• Number of years under present management:
• How many years of management experience do you have?
• Do you ever process payment cards? Yes No
• Estimated annual number of payment card transactions:
• `
• Does the Applicant have a formal safety training program for employees? Yes No
• Does the Applicant have a safety manager on premises at all times the facility is open? Yes No
• If yes, please provide the name and contact information:
• Desired Effective Date:



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