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Company Info
General Info
Policy Claims
Supplements
Equipment
Fraud Page
Confirmation
Section 4: DEVICE SUPPLEMENTS
If you have any of the following devices please fill out the supplemental information. If you do not own any of the devices below please answer no for each section to proceed.
Rock Wall Supplement
Do you own a Rockwall?
Yes
No
Manufacturer:
American Rock Climbing
Vertical Reality
Extreme Engineering
Spectrum Sports/Rebound Active Sports
Other
If other, please type in the manufacturer:
Is it an inflatable Rockwall?
Yes
No
If yes, is it Manual or Auto Belay:
Manual
Auto
The Rockwall is:
Indoor
Outdoor
Rockwall supervised at all times:
Yes
No
Is there a formal maintenance checklist program:
Yes
No
Is there a formal employee safety training program?
Yes
No
Is the tool loop cut off from the safety harness?
Yes
No
When the rockwall is not used, how and where do you store it?
How often are the cables replaced?
Rockwall Belay is:
Manual
Automatic
Date Rockwall manufactured?
Trackless Train Supplement
Do you have a Trackless Train?
Yes
No
Please continue on to the next page.
Manufacturer:
How many cars?
Back Brakes?
Yes
No
Does the train have a rearview mirror to view the last cars?
Who is the conductor?
Is train run at a mall or strip mall?
Yes
No
If yes, which one?
Strip Mall
Mall
Is this an outdoor mall?
Yes
No
Does landlord have special insurance requirements?
Yes
No
Is the train driven in areas where there is moving traffic, such as parking lots or outdoor malls (driveways & roads or pedestrian walkways)?
Yes
No
If yes, describe the route in detail:
Are Customers:
Residential
Corporate
Fairs & Festivals
Traveling Carnivals
How is train transported to event sites?
Is there waiver signage on or near the train, clearly visible to all participants?
Yes
No
Please attach a photo of your train
Please send a copy of the waiver signage Wording
Next Page
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