Fillable AR Amusement Application 07.19

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AR Amusement Application 07.19

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Amusement/Family Entertainment Center (FEC) 02.20 Page 1 of 14
APPLICATION FOR: Amusement/Family Entertainment Center (FEC)
Email: rgerbers@aliverisk.com or tbillig@aliverisk.com
Notice: The Policy for which this Application is made, subject to its terms, applies only to any Claim (as applicable in the Coverage
Section for which Application is made) made against any of the Insureds during the Policy Period. The Limit of Liability available to pay
damages or settlements shall be reduced and may be exhausted by amounts incurred as Costs, Charges and Expenses (as defined in the
Coverage Section for which Application is made), and Costs, Charges and Expenses shall be applied to the retentions. Submission of
this Application does not guarantee coverage.
SECTION I. SUBMISSION REQUIREMENTS
Completed & Signed Alive Risk Supplemental and ACORD 125 & 126 Applications
5 Years Loss Runs - Currently valued
Copy of current waivers
Copy of Employee Training, Safety, and Maintenance Manuals
Copy of Daily Maintenance Checklist/Logs
Copy of Incident Report Form
Website information, brochures and/or photos, of each attraction
Copy of any existing State Certifications and/or Inspections
Ownership Breakdown, Experience and/or Resume
Certificate of Insurance from any Sub Contractor and/or Independent Contractor
Copy of all agreements including Lease Agreements, Subcontractor Agreements, etc.
SECTION II. GENERAL INFORMATION
Contact Person: Contact Person Title:
Phone No.: Fax No.:
Email: Website:
Name of Insured (“Applicant”):
DBA: Insured is Corp LLC Other:
Mailing Address:
City, State, Zip:
Premises Address:
City, State, Zip:
Is the proposed insured a subsidiary of another company? Yes No
If yes, name of parent company
Does facility comply with ADA Requirements? Yes No
Size of facility: Square Footage: Indoor: Outdoor: Acreage:
Number of years in business: Number of years under current management:
Have you used any Amusement Facility Consultant? Yes No
If yes, whom?
Amusement/Family Entertainment Center (FEC) 02.20 Page 2 of 14
Proposed Effective Date: Expiration Date:
Prior Insurance Carrier: Has insurance ever been canceled? Yes No
What is your expiring premium for General Liability? Excess?
Limits requested?
What associations do you belong to?
Hours of operation: Operating Season:
Are you aware of any circumstances that may result in a claim made against you? Yes No
If yes, please describe:
SECTION III. PREMISES INFORMATION
Do you own or lease premises? Other occupancies:
Describe parking facilities - location, lighted, sloped, etc.:
Describe type of security (armed/unarmed) for parking, facility, etc. :
If hired security, is Certificate of Insurance provided naming you as an additional insured? Yes No
If security is in-house, what type of training is provided?
Is Assumption of Risk signage present? Yes No
If yes, describe type, location and provide photos
Are waivers signed for any of the attractions? Yes No
If yes, which attractions?
Number of surveillance cameras Inside: Outside: Total:
Name of surveillance system: How long do you store video?
Does surveillance capture waivers being signed? Yes No
Number of employees certified in CPR & First Aid:
Is there at least one employee, certified in CPR and First Aid, present at all times? Yes No
Describe medical facilities provided:
Describe how injuries and medical emergencies are handled and by whom?
Are there any employed nurses or physicians? Yes No
Are there any programs that allow overnight stays? Yes No
If yes, describe:
Any operations sold, acquired or discontinued in the last 5 years? Yes No
Any storage, disposing, discharging or transporting of hazardous materials? Yes No
Amusement/Family Entertainment Center (FEC) 02.20 Page 3 of 14
If yes, describe:
Do ALL Attractions, Equipment and Fencing meet ASTM standards? Yes No
Do you sponsor any sporting, competitions or social events? Yes No
If yes, explain:
Do you host any special and/or live events? Yes No
If yes, describe:
Do you have any interest in Active Shooter coverage? Yes No
SECTION IV. FINANCIAL INFORMATION *Must provide current Financial Statement to verify receipts*
A. ATTRACTION INFORMATION: GROSS ANNUAL RECEIPTS (Current and Next Year Estimated)
Total Gross Receipts: Average Annual # of Attendance:
Attraction
Revenue
Attraction
Revenue
Arcade/Simulators
Mechanical Rides
Axe Throwing
Mini-Golf
Batting Cages
Ninja Course
Bowling
Rock Wall/Climbing
Bumper Boats
Roller Skating
Bumper Cars
Ropes Course
Escape Rooms
Soft Play
Driving Range
Zip Lines
Go Karts
Food
Inflatables
Liquor
Laser Tag
Merchandise
Other
Other
PLEASE NOTE: Our policy is a “scheduled” policy meaning that all attractions to be covered under the policy must be listed on our
policy. Please list/provide any other attractions not listed above:
SECTION V. OPERATIONS
A. ARCADES N/A
Number of machines: Any coin-operated rides? Yes No
If yes, how many?
Any ride simulators or interactive games? Yes No
If yes, describe and list:
Are machines grounded properly? Yes No
Are machines owned or leased? *If leased, provide agreement. Owned Leased
Amusement/Family Entertainment Center (FEC) 02.20 Page 4 of 14
Who provides maintenance/service on machines?
How many attendants are present in arcade area?
B. AXE THROWING N/A
Number of lanes: Maximum distance thrown:
Number of range supervisors: Ratio of supervisors to lanes:
Number of annual participants:
Are axe throwing lanes in compliance with IATF and WATL? Yes No
If no, please explain:
Do axe throwing lanes have age restrictions? Yes No
If yes, please describe:
Are each lane separated by barriers? Yes No
If no, please explain:
What type of flooring on each lane (e.g. rubber, wood)?
Are rules and assumption of risk signs prominently displayed? Yes No
Are participants provided lessons prior to throwing? Yes No
If yes, please describe:
What type of certification of range supervisors:
C. BATTING CAGES N/A
Who is the manufacturer? Minimum age of participants:
Number of machines: Slow pitch Fast pitch
Maximum ball speed in Slow Pitch: Maximum ball speed in Fast Pitch:
Balls approved by manufacturer? Yes No
Are machine velocities checked or calibrated? Yes No
If yes, by whom?
Are records kept? Yes No
If yes, how long?
Are home plates clearly marked for left and right handed participants? Yes No
Can pitching machines be altered by participants? Yes No
Are helmets required? Yes No
Is there a light indicator when last ball has been pitched? Yes No
Are participants allowed to swing bats outside of batting cages? Yes No
Are ALL the rules posted on cage indicating warnings and rules? Yes No
How many supervisors are present?
D. BOWLING N/A
Number of lanes: Lane construction: Wood Synthetic Lane finish Oil Base Water Base
Hours of operation: Do you contract lane refinishing? Yes No
If yes, who is responsible?
*Provide agreement.
How are food and drinks restricted from bowling area?
Are ball racks secure and anchored to the floor? Yes No
Are tables secure and anchored to the floor? Yes No
Amusement/Family Entertainment Center (FEC) 02.20 Page 5 of 14
Do you sponsor any professional tournaments? Yes No
If yes, list organizations:
Do you collect Certificates of Insurance for organization listing you as an additional insured? Yes No
Describe Rules/Warnings/Assumption of Risk signage (including bowlers “not crossing the foul line”):
Do you allow patrons to bring their own wine/beer? Yes No
Is the pro shop run by an independent contractor? Yes No
If yes, do they have proof of insurance AND are you listed as an additional insured on policy? Yes No
Percentage of open play: Percentage of league play:
E. BUMPER BOATS N/A
Who is the manufacturer?
Number of boats: Maximum engine horsepower:
Minimum age requirements: Minimum height requirements:
Are the bumper boats completely fenced in? Yes No
Height of spectator fence: How far away are spectators from action?
Describe water rescue equipment and procedures:
Depth of water: Can you see the bottom? Yes No
How old is the oldest boat? How are propellers protected?
How is gas stored?
Where is gas stored? How far away from pool?
Are all Assumptions of Risk, warnings and rules clearly posted at entrance? Yes No
How often are boats inspected? By whom?
Are records kept? Yes No If yes, how long?
How many staff supervisors are present?
Has Insured ever manufactured or retrofitted any bumper boats? Yes No
If yes, describe:
F. BUMPER CARS N/A
Who is the manufacturer?
Number of cars: Oldest car:
Are all cars equipped with dash, headrest and steering pads? Yes No
Are seat belts required? Yes No
How are spectators restricted from going onto the floor while cars are in motion?
Are Assumption of Risk, warnings and rules clearly posted at entrance? Yes No
Amusement/Family Entertainment Center (FEC) 02.20 Page 6 of 14
Size of floor: How many attendants?
How often are cars inspected? By whom?
Are records kept? Yes No
If yes, how long? *Provide copy of records.
Has Insured ever manufactured or retrofitted any bumper cars? Yes No
If yes, describe:
G. DRIVING RANGE N/A
Number of stalls: Are there partitions? Yes No
If yes, what is the height? What is the width?
Construction of partition: Distance between partitions:
Number of levels:
Describe safety features preventing falls from multilevel facility:
Do you sponsor professional and/or events with 250+ people? Yes No
If yes, describe:
H. ESCAPE ROOMS N/A
Number of rooms: Number of players per room:
Describe the room scenario for each:
Are there employee actors involved in any of the scenarios? Yes No
If yes, describe:
Are participants provided written safety procedures and rules? Yes No
Do participants sign a waiver? Yes No
Are participants monitored at all times? Yes No
Are there surveillance cameras on each room? Yes No
How many employee monitors per room?
Are any tasks physical in nature that can cause injury? Yes No
If yes, please explain:
I. GO KARTS N/A
Who is the manufacturer? Gas Electric
Amusement/Family Entertainment Center (FEC) 02.20 Page 7 of 14
Number of tracks: Number of single karts: Number of double karts:
Number of attendants on each track: Number of karts allowed on the track at one time:
Number of extinguishers: Type of track:
Type of track surface:
What type of barrier system is around the track?
How are spectators protected from karts?
How far are spectators from track? Maximum speed of karts:
Are governors installed on each kart? Yes No
Minimum age requirements: Minimum height requirements:
Do you allow racing? Yes No Is the track fenced? Yes No
Type of instructions given: Verbal Video loop Recorded message Written
Are helmets required? Yes No Is there an operator shut off system? Yes No
Number of attendants per track: Number of fire extinguishers around track:
Describe track signage:
How often are karts inspected? By whom?
*Please Provide Checklist of inspection.
Are participants required to wear shoes? Yes No
Are waivers required? *If yes, provide copy of waiver. Yes No
Are there any modifications to the kart different from manufacture guidelines/requirements? Yes No
If yes, what modifications have been made?
What is the amount of gas stored on premises at one time?
Where is gas stored? How is gas stored?
How far away is gas stored from track? How old is the oldest kart?
*Please provide a diagram of tracks.
J. INFLATABLES N/A
Who is the manufacturer? Number of inflatables:
Number of inflatables off premises: Number of indoor inflatables:
Type of flooring in inflatable area: Number of outdoor inflatables:
How are they anchored/secured/tied down?
Describe each inflatable:
Who is responsible for inspections? How often are inflatables inspected?
*Provide inspection/maintenance procedures.
Are waivers required? *If yes, provide copy of waiver. Yes No
Is each inflatable manned by an attendant/operator? Yes No
Amusement/Family Entertainment Center (FEC) 02.20 Page 8 of 14
Describe training:
Describe signage:
Describe controls to prevent double bouncing and when participants with different sizes / abilities are grouped together:
Type of instructions given: Verbal Video loop Recorded message Written
K. LASER TAG N/A
Who is the manufacturer?
Ratio of judges to participants: Are games refereed? Yes No
Minimum age requirements: Minimum height requirements:
Maximum number of participants at one time: Square footage of area:
Type of instructions given: Verbal Video loop Recorded message Written
Describe Rules/Warnings/Assumption of Risk signage (including bowlers “not crossing the foul line”):
Do you lease or own equipment? *If lease, provide lease agreement. Lease Own
Do you repair OR modify equipment? Yes No
If yes, describe modifications:
Describe any ramps, barriers, steps, etc.:
Are there elevated structures? Yes No
If yes, how high?
How often do you inspect equipment? Is there a maintenance log kept? Yes No
Is there an emergency lighting system? Yes No
Are there surveillance cameras specifically on the floor/main playing and staging area? Yes No
Describe:
L. MECHANICAL RIDES/KIDDIE RIDES N/A
Who is the manufacturer? Number of rides:
Does each ride and mechanical device meet ASTM – F-853 standards? Yes No
Number of inflatables off premises: Number of indoor inflatables:
If no, explain:
Do ALL rides comply with manufacture recommendations with regard to Height, Age, Weight, & Exit Requirements? Yes No
*List all rides – per schedule attached.
Amusement/Family Entertainment Center (FEC) 02.20 Page 9 of 14
Has Insured ever manufactured or retrofitted any mechanical ride? Yes No
If yes, list attraction and the changes made:
How often are rides inspected? Is there an inspection log? *If yes, provide copy. Yes No
Describe qualifications of the maintenance staff:
Where is the maintenance conducted for rides?
Are all rides inspected and certified by a licensed inspector annually? Yes No
Are all manuals of rides kept on premises? Yes No
Are there rides where the operator controls the speed? Yes No
If yes, explain which rides AND staff training that is required:
Describe barrier system keeping spectators away from rides:
Describe safety signage around rides:
M. MINIATURE GOLF N/A
Who is the manufacturer/developer of course?
Number of courses: Number of holes: Estimated elevation from lowest hole to highest hole:
Are walkways clearly marked, especially for stairs? Yes No
Are proper warning signs displayed throughout the course and at #1 hole/counter? Yes No
Do all water fountains/falls have ground fault interrupters in place? Yes No
Are all putters rubber protected? Yes No
Describe lighting:
N. NINJA COURSE N/A
Who is the manufacturer?
Ratio of monitors to participants: Is a monitor present at all times? Yes No
Minimum age: Minimum height: Maximum number of participants:
Square footage of course:
Type of instructions given: Verbal Video loop Recorded message Written
Describe Rules/Warnings/Assumption of Risk signage:
Is there a Salmon Ladder obstacle? Yes No
Is there a Warp Wall obstacle? Yes No
List the different type of obstacles/elements:
Amusement/Family Entertainment Center (FEC) 02.20 Page 10 of 14
Is the course: Ground level Elevated Multi-level
Describe padding and safety netting system below the obstacles:
Is the course separated into child and adult level of difficulty? Yes No
Do you repair OR modify equipment? Yes No
If yes, describe modifications:
How often do you inspect equipment? Is there a maintenance log kept? Yes No
Are surveillance cameras able to see all elements of the course? Yes No
O. ROCK CLIMBING N/A
Who is the manufacturer? Who installed Walls?
Are participants allowed to climb on their own? Yes No
Number of walls: What is the height of the Bouldering/Traversing wall?
Are spotters required? Yes No
How are participants checked in?
Does rock wall meet all CWIG (Climbing Wall Industry Group) standards? Yes No
What type of safety equipment is used?
Describe the belay system:
Describe Safety Inspection policy for wall, hardware, equipment and rental gear:
Who is responsible for maintenance inspections?
How often are inspections done? Is there a waiver signed? Yes No
*If yes, provide copy.
Describe employee training procedures?
What type of assumption of risk signs (indicating age, size, height, rules, etc.)?
Type of instructions given: Verbal Video loop Recorded message Written
Describe landing surface – thickness, makeup, extent of fall protection:
Are there any mobile rock walls? Yes No
If yes, how often are they off premises?
How many attendants are stationed at each rock wall?
Amusement/Family Entertainment Center (FEC) 02.20 Page 11 of 14
P. ROLLER SKATING N/A
Member of RSA? Yes No Do you offer any "all night" or “midnight” skating? Yes No
If yes, what ages are allowed? What are the hours?
Maximum number of Skaters per Floor Guard during sessions: Rink Floor Capacity:
Number of Skating Surfaces: Floor Material: Age:
Is there regular scheduled maintenance of the floor? Yes No
Is the rink utilized/rented out for non-skating activities? Yes No
If yes, list events:
Is there a written contract between the rink and the party utilizing/renting out facility? Yes No
Are safety rules, rules of conduct and assumption of risk posted throughout the facility? Yes No
Are roller skating lessons conducted? Yes No
If so, are the instructors employees? Yes No
Are participant waivers collected for skating lessons? Yes No
Do you conduct regular maintenance, inspection and replacement of rental skates? Yes No
Do you keep a skate maintenance log? Yes No
Do you number your skates? Yes No
Explain briefly the overall maintenance and housekeeping of premises:
Q. SOFT PLAY N/A
Who is the manufacturer? Who installed the equipment?
Number of monitors: Square Footage: Number of levels:
Is the soft play area fully enclosed and age restricted? Yes No
Maximum age: Maximum height:
How often is area inspected? Is there a maintenance log kept? Yes No
How often is area cleaned? Is there a cleaning log kept? Yes No
Type of flooring under equipment:
Describe Rules/Warnings/Assumption of Risk signage:
Has Insured modified or retrofitted the manufacturer’s recommendations? Yes No
If yes, describe:
R. ZIP LINES/ROPES COURSE N/A
Who is the manufacturer? What year was course built?
Who originally installed/built the course?
Have any additions/modifications been made after course was originally constructed? Yes No
If yes, describe additions/modifications and year completed:
Number of zip lines: How many feet is the longest zip line?
Number of elements: What is the height of the elements?
Amusement/Family Entertainment Center (FEC) 02.20 Page 12 of 14
List/describe elements:
Describe fall protection systems at Transfer Stations:
Describe zip line braking system:
Describe emergency plan if patron is stranded on the zip line:
Describe participant lanyard system at Transfer Stations:
How often is course inspected? By whom?
*Provide inspection checklist and training manual.
What is staff to participant ratio?
Have there been any issues with State Inspections? Yes No
If yes, describe:
Are participants notified of difficulty levels at Transfer Stations? Yes No
What is the approximate time a participant will take to complete the course?
What is the maximum number of elements a participant must complete before they have an opportunity to exit the course?
Are there any zip lines or ropes courses that can be moved from property or mobile? Yes No
Does the course have a supervised practice area? *Provide diagram of course. Yes No
Do you follow the ANSI/PRCA American National Standard (ANS)? Yes No
S. RESTAURANT/SNACK BAR N/A
Restaurant exposure: Full-Service Snack Bar Lessor’s Risk Square foot?
Is food area lease/subcontracted out? Yes No
If leased, does insured receive COI from sub contractor listing them as an additional insured? Yes No
*If yes, provide contract.
Are alcoholic beverages sold on premises (e.g. beer, wine, liquor)? Yes No
Are portable fire extinguishers provided in kitchen? Yes No
Who is responsible for cleaning hoods and ducts? How often?
Are cleaning records kept? Yes No
Number of each: Deep Fryers: _________ Ovens: _________ Grills: _________ Broilers: _________ Ranges: _________
Describe maintenance/inspections procedures:
Have there been any issues with State Inspections? Yes No
If yes, explain:
T. CHILD CARE/CHILD DROP-OFF/LOCK-INS N/A
What is the maximum number of children dropped off/left in your care at one time?
Amusement/Family Entertainment Center (FEC) 02.20 Page 13 of 14
What is the ratio of monitors to children left in your care? What is the minimum age of a child left in your care?
What are the maximum hours per day that a child may be in your care?
What type of system do you have in place for checking in/out children when they arrive and depart?
Do you have written training/safety procedures including performing background checks on employees or volunteers in charge
of drop-off service? *If yes, provide a copy. Yes No
Briefly describe the programs you offer for children to be dropped off and supervised by employees:
U. HIRED AND NON-OWNED N/A
Do you have a Business Auto Policy for owned autos? Yes No
If yes, NOTE – Coverage should be placed under your Auto Carrier.
Does insured allow employees/volunteers to use their personal vehicles for business purposes? Yes No
If yes, how often?
Total number of Employees: Total number of Volunteers:
Does insured obtain Motor Vehicle Reports? Yes No
If yes, how often?
What are the auto minimum limits the insured requires of their employees/volunteers?
How often does insured lease, borrower or hire any vehicles for business?
What type of vehicles are used and for what purposes? _
The undersigned declares that to the best of his/her knowledge the statements herein are true. Signing of this Application does not bind
the undersigned to complete the insurance, but it is agreed that this Application shall be the basis of the contract should a Policy be
issued, and this Application will be attached and become a part of such Policy, if issued. Underwriters hereby are authorized to make any
investigation and inquiry in connection with this Application as they may deem necessary.
It is warranted that the particulars and statements contained in the Application for the proposed Policy and any materials submitted
herewith (which shall be retained on files by Underwriters and which shall be deemed attached hereto, as if physically attached hereto),
are the basis for the proposed Policy and are to be considered as incorporated into and constituting a part of the proposed Policy.
It is agreed that in the event there is any material change in the answers to the questions contained herein prior to the effective date of the
Policy, the applicant will notify Underwriters and, at the sole discretion of Underwriters, any outstanding quotations may be modified or
withdrawn.
Submitted by: Applicant Signature:
(Agent)
Date: Name:
(Please Print)
Title:
Date:
Amusement/Family Entertainment Center (FEC) 02.20 Page 14 of 14
SCHEDULE OF ATTRACTIONS
Description
Manufacturer
Serial Number
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AR Amusement Application 07.19

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Completed 20 July 2020

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