AMUSEMENT DEVICES OR RIDES SUPPLEMENTAL GENERAL LIABILITY APPLICATION

(Complete in addition to ACORD General Liability application)

Name of Applicant:

1. Applicant’s experience:

Number of years in operation:

If a new operation, the number of years of related experience:

2. Schedule of Amusement Devices or Rides:

Name and/or Type of
Amusement Device or Ride / Age / Manufacturer / Capacity / Maximum
Operating Speed

Does the applicant have any animal rides or animal exposures? Yes No

If yes, please describe:
For amusement rides, describe the height and type of fencing required for spectator safety:

3. Rides:

Do rides have signs clearly marking age, height, and size limitations? Yes No

Are all rides inspected? Yes No

If yes, please provide details of the inspection process:
Who Completes the Inspections? / Frequency of
Inspection? / Are Inspection/Maintenance
Logs Maintained?
Yes No
Yes No

4. Receipts:

What are the applicant’s estimated annual receipts? $

5. Supervision:

Please describe the nature of the adult supervision provided while any ride or device is in use:

6. List states in which applicant operates:

7. Total number of employees:

Are any employees leased? Yes No

8. Does applicant have a training program? Yes No

This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the information contained herein shall be the basis of the contract should a policy be issued.

APPLICABLE IN THE STATE OF NEW YORK:

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.

FRAUD WARNING (APPLICABLE IN TENNESSEE AND WASHINGTON):

It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

FRAUD WARNING:

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 subjects such person to criminal and civil penalties.

APPLICANT’S SIGNATURE: Date

AGENT NAME: AGENT LICENSE NUMBER:

(Applicable to Florida Agents Only.)

NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT:
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written requests, additional information
as to the nature and scope of the report, if one is made, will be provided.

ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE”

Please send completed application to , and / or

WHI SUP-21-027 (08-07) Page 2 of 2

Pacificcoastes.com / Santa Rosa / T 880-772-8538 / F 707-573-9761
Seattle / T 800-528-5695 / F 206-329-7096