Castle Rock Agency Inc
853 Broadway 1602
New York, NY 10003
V: 212-360-2334
F: 800-978-5182
[email protected]
CastleRockAgency.com
HAUNTED HOUSE INSURANCE APPLICATION
GENERAL INFORMATION
1.
Named Insured (Applicant): _____________________________________________________________
2.
a. Address:__________________________________________________________________________
City: ____________________________________
b. Describe Applicant’s role & responsibility in event:
State: ______________
Zip: ____________
__________________________________________________
_____________________________________________________________________________________________________
3.
4.
Phone: _____________________ Fax: _______________________ E-mail: _____________________
Additional Insured Name
5.
Address
Interest In Event
a. Full schedule/description and purpose of event (Attach copy of brochure and/or flyer to this application)
___________________________________________________________________________________________________
b. Is this part of a larger function? __ Yes __ No
c. Is there an admission charge? __ Yes __ No
6.
a. Dates of event:
b. Desired coverage dates:
If “Yes,” describe: __________________________________
If “Yes,” cost of admission per person: ______________
From: _____/_____/_____
From: _____/_____/_____
To: _____/_____/_____
To: _____/_____/_____
c. If event date(s) differ(s) from desired coverage date(s), explain: _____________________________________
_____________________________________________________________________________________________________
d. Hours of Event:
From: _______ am/pm
To: ______am/pm
If Hours vary by Date, describe:
_____________________________________________________________________________________________________
7.
Location of event (Name and address) _________________________________________________________________
Location is:
__ Private Residence __ Liquor-Licensed Establishment
__ Indoors
__ Convention Center __ Stadium
__ Outdoors
__ Arena
__ Fair Grounds
__ Other ____________
Attach a diagram of location. If event is held outdoors, indicate fencing, adjacent building, and landscape features.
8.
ESTIMATED ATTENDANCE PER DAY ____________ TOTAL ___________ Average age of attendees: ____________
Maximum Capacity of facility ______________ Attendance is: __ by Invitation Only
9.
10.
Policy Experience:
Number of years event has been previously held:
Actual total attendance for Prior Year’s event:
Premium/Loss Information:
Policy Year
20____
20____
__ Open to the Public
__________________
___________________
20____
Total Premium
Carrier & Policy #
Total # of Claims
Total $ Paid/Reserved
Special Event Application Page 1 of 3
11. Has any insurance carrier cancelled or refused coverage?
__ Yes
__ No
If “yes”, please explain: _________________________________________________________________________________
_________________________________________________________________________________________________________
12. Does facility require a contract for usage?
13. Limits of Liability requested:
__ Yes
__ No
__ $1,000,000
If “Yes,” provide copy of contract(s).
__ Other
__________________________
COMMERCIAL GENERAL LIABILITY SECTION
14. Will event feature any of the following:
a. Rides, mechanical devices, rebounding devices (ie: moonbounce, trampoline)?
b. Petting Zoo, animal rides?
c. Fireworks/Pyrotechnics?
15. a. Are Vendors, Attraction Owners and Performers required to carry their own insurance?
If “Yes,” what limit is required? ______________________________________________________
__ Yes
__ Yes
__ Yes
__ No
__ No
__ No
__ Yes
__ No
b. Will concessionaires provide you with certificates evidencing products liability with your organization
named as Additional Insured?
__ Yes
__ No
__ No Concessionaires
16. Who contracts security?: a. __ Facility
__ Applicant
b. Number of Security Personnel ______________
17. a. Describe security measures: __________________________________________________________________________
b. Is security provided by:
__ Independent Contractors
__ Employees of the Applicant
__ On-Duty Police __ Off-Duty Police
__ Guard Dogs
c. If security provided by Independent Contractors, are they required to carry their own insurance?
__ Yes
18. Number of grandstands, if any: __________________________
__ Permanent __ Temporary
__ No
If temporary, list name of firm doing installation: _________________________________________________________
19. Seating capacity:
______________
Construction Type of grandstands: __________________________________
20. a. Emergency evacuation plan in place?
b. Qualified medical personnel in attendance?
c. Ambulance service in attendance?
__ Yes
__ Yes
__ Yes
__ No
__ No
__ No
21. If MUSICAL/ENTERTAINMENT event:
Performer/Entertainer Name
Type of Music/Program
Local or National ?
__ Local
__ Local
__ Local
__ Local
Is dancing permitted at this event?
22. If PARADE event:
__ No
a. Number of Floats: ______________
c. Length of Parade:
23. If ATHLETIC event:
__ Yes
__ National
__ National
__ National
__ National
_______________________
Number of Games: _______________
b. Number of Marching Units: ________________
d. Estimated number of spectators: _______________
Number of Spectators: ___________________
__ Professional? __ Amateur? # Youth Participants/Players ________ # Adult Participants/Players _________
Special Event Application Page 2 of 3
LIQUOR LIABILITY
__ Quotation Required
__ Quotation Not Required
24. ESTIMATED NUMBER OF ATTENDEES CONSUMING ALCOHOL DAILY:
____________________________
25. a. Is Applicant sole vendor of alcohol at Event:
__ Yes
__ No
If “No,” List number of other Vendors serving alcohol: _____________
b. Are all participating alcohol Vendors required to carry minimum Liquor Liability Limits for the Event?
__ Yes
__ No
If “Yes,” what is the Minimum Requirement? ___________________________________________________________
26. a. Will alcohol be dispensed by a Professional Bartender?
__ Yes
__ No
If “No,” describe how and by
whom alcohol will be dispensed: ________________________________________________________________________
b. Describe training and/or experience of persons serving alcohol: _________________________________________
_________________________________________________________________________________________________________
c. What measures are in place to prevent service of alcohol to minor and/or intoxicated persons?
_________________________________________________________________________________________________________
27. a. Is Liquor License required for this event?
b. Does Applicant have a valid Liquor License?
__ Yes
__ Yes
__ No
__ No
28. a. Number of bars or areas at which alcohol will be dispensed at the Event: ________________________________
b. Is alcohol consumption confined to this (these) areas? __ Yes
__ No
If “No,” describe: ________
_________________________________________________________________________________________________________
c. Will there be an open bar? __ Yes __ No
d. Will alcohol be sold by the drink?
__ Yes
f. Is BYOB (Bring your own bottle) permitted? __ Yes
e. Cost per drink: ______________________
29. Will food be sold or served?
__ Yes
__ No
If “Yes,” describe type of food available:
__ No
__ No
__________________
____________________________________________________________________________________________________________
30. Estimated gross receipts per day:
Alcohol _______________
Food _________________
FRAUD STATEMENT: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON,
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS
FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE
ACT, WHICH IS A CRIME AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE
STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
WARRANTY STATEMENT: I HEREBY WARRANT AND CONFIRM THAT THE ABOVE INFORMATION, TO THE BEST OF MY KNOWLEDGE, IS
TRUE AND CORRECT, AND FURTHER CERTIFY THAT I HAVE READ ALL OF THE QUESTIONS AND ANSWERS ON THIS APPLICATION.
I UNDERSTAND THIS APPLICATION IS A REQUIREMENT FOR COVERAGE, A PART OF THE CONTRACT AND EVIDENCE OF MY ACCEPTANCE
OF THIS INSURANCE, AND ANY FALSIFICATION OR MISREPRESENTATION WILL BE DEEMED A BREACH OF CONTRACT, VOIDING ALL
INSURANCE COVERAGE.
IT IS UNDERSTOOD AND AGREED THAT THE COMPLETION OF THIS APPLICATION SHALL NOT BE BINDING EITHER TO THE PROPOSED
INSURED OR THE COMPANY UNTIL ACCEPTED BY THE COMPANY OR COMPANIES IN WRITING.
____________________________________________________________________
Name of Applicant (Please Print)
__________________________________________
Title
____________________________________________________________________
Signature of Applicant
__________________________________________
Date
IF THE APPLICANT IS LOCATED IN THE STATE OF NEW YORK, THE STATE OF NEW YORK REQUIRES THAT WE HAVE THE NAME AND
ADDRESS OF YOUR (INSURED’S) AUTHORIZED AGENT OR BROKER.
Castle Rock Agency
NAME OF AUTHORIZED AGENT OR BROKER _____________________________________________________________________________
853 Broadway 1602 New York NY 10003
ADDRESS ___________________________________________________________________________________________________________
MAIL COMPLETED APPLICATION THROUGH LOCAL AGENT OR BROKER TO:
Special Event Application Page 3 of 3
HAUNTED ATTRACTIONS SUPPLEMENT
Applicant’s Name:
________________________________________________________________
Applicant Organization Type (IE: Church/Kiwanis): _______________________________________
Opening Date: _______________________
Closing Date: ____________________________
General Liability Limit Requesting: _____________________________________________________
Estimated Number of Patrons for entire period: ____________________________________________
Estimated GROSS Receipts for entire period: _____________________________________________
Is Haunted House an EXISTING STRUCTURE or TEMPORARY? ___________________________
Number of years Applicant has held Haunted House event: __________________________________
Number of stories for the structure/house: ________________________________________________
Are all ENTRANCES, EXITS, and/or STEPS adequately lit? ________________________________
Are all STAIRS and/or STEPS adequately equipped with Handrails? __________________________
Are there any RAMPS, SLIDES, TRAP DOORS or MOVING FLOORS? ______________________
• If YES, please explain in detail: __________________________________________________
Will Live Actors be used in the Haunted House? __________________________________________
Will any Actors be in ANY TYPE of contact with Patrons? __________________________________
• If YES, please explain in detail: __________________________________________________
Will Children under 6 years of age be required to be accompanied by an Adult? __________________
Will any Animal(s), Reptile(s), or “Hangman’s Noose(s)” be used? ____________________________
Will any “Moonwalks” or similar devices be used? ________________________________________
___________________________________
AGENT’S SIGNATURE
____________________________
DATE
___________________________________
APPLICANT’S SIGNATURE
____________________________
DATE
Email Application
HAUNTED ATTRACTIONS
HAUNTED HOUSE/GRAVEYARD
HAUNTED HAYRIDES/WALKS
WARRANTIES
1. No Mechanical Devices or Machinery with Moving Parts
2. No Buildings Over One Story
3. No Chutes, Slides, Trap Doors, Movable or Sharply Inclined Floors
4. No Use of Live Animals
5. No Physical Contact or Jumping Out at Patrons by Actors
6. Warnings Posted for Pregnant Women and/or Those with Heart Conditions
7. No Open Flames
8. All Steps to be well Lighted and Include Handrails
9. Adequate Emergency Lighting
10. Exits Well Marked
11. Buildings Must Meet or Exceed Local Zoning and Fire Codes
12. Hayrides Must Be Tractor Drawn – No Horse Drawn Hayrides
13. Hayrides Must Be On Private Property – No Public Roads
I AGREE TO ALL OF THE ABOVE WARRANTIES WITHOUT EXCEPTION.
________________________
Signature of Applicant
________________________
Date
Email Application
_________________________
Print Name