POLICY RECOMMENDATIONS(Please check any you are interested in)
Accident Medical
Inland Marine
Worker's Compensation
Commercial Auto
EPLI
Hired & Non-Owned Auto
Umbrella
Abuse/Molestation
Cyber Liability
Submission Requirements
1) Loss Runs (5 years)
2) No loss letter if operating with no insurance
3) Copy of Rental Agreement / Waiver
4) Safety Rules
5) Pictures of signage with hold harmless wording (Pay for Play Only)
6) Diagram Filled Out
Section 1: COMPANY INFORMATION
How did you hear about us?
Choose One
Bing
Customer Referral
Google
Manufacturer
Other
Postcard
Social Media
Trade Show
Yahoo
Are you an ERS or Inflatable Office customer?
Yes
No
Name of Insured:
FEIN/SS#:
DOB:
Address
Address/PO Box:
City:
State:
Zip code:
Phone Number:
Contact Name:
Website:
Email:
Is named insured a?
Corporation
Partnership
Individual
LLC
Other:
Years in business:
# of Bulls Owned:
Annual Gross Rev:
Do you ever process payment cards?
Yes
No
Estimated annual number of payment card transactions:
Number of Employed Operators
Full Time:
Part Time:
Annual Payroll:
Names of all operators:
If independent contractors are ever used to operate, est. annual costs for such labor $
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.