Fillable AMUSEMENT PROGRAM SUPPLEMENTAL GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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AMUSEMENT PROGRAM SUPPLEMENTAL GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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GL-APP-33g (10-17) Page 1 of 4
AMUSEMENT PROGRAM SUPPLEMENTAL GENERAL LIABILITY APPLICATION
(Complete in addition to ACORD General Liability Application)
Applicant’s Name:
Location Address:
Agency Name:
_________________________________
Agent No.:
Phone No.:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
1. Description of operation:
Number of years in operation:
Years of experience in this field:
2. Schedule of Amusements (owned or leased):
Name and Type of Amusement No. Age Manufacturer
Capacity
Maximum
Operating
Speed
Receipts
a. Does applicant have any animal rides or animal exposures? ............................................................... Yes No
If yes, please describe:
b. Does applicant have any zip lines? ....................................................................................................... Yes No
c. For batting cages, are participants required to wear protective headgear? ......................................... Yes No
d. For paddle boats:
Are U.S. Coast Guard approved life preservers provided and required for each passenger? .............
Yes No
Are paddle boat renters required to sign hold harmless agreements in the applicant’s favor? ............ Yes No
GL-APP-33g (10-17) Page 2 of 4
e. For carriages, sleighs or hayrides, are passengers driven on public streets or roads? ....................... Yes No
f. For hot air balloon rides, are balloons tethered? .................................................................................. Yes No
If yes, maximum height of balloon: ft.
g. For laser tag centers, is center on more than one level? ...................................................................... Yes No
If yes, please describe:
h. Does applicant own or lease any inflatable amusement devices? ....................................................... Yes No
If yes, please describe:
3. Mechanical Rides:
a. Do rides have signs clearly marking age, height and size limitations? .................................................
Yes No
b. Describe the height and type of fencing required for spectator safety:
c. 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. Scenic Trains:
a. How often is the train maintained and inspected?
b. How often are the tracks maintained and inspected?
c. Are tracks shared with other trains? ..................................................................................................... Yes No
d. What is the maximum speed of the train?
e. How many times do the tracks cross streets/roads?
f. Are traffic safety devices in place at each street/road crossing? .......................................................... Yes No
g. Are engineers subject to drug and alcohol testing? .............................................................................. Yes No
h. What is maximum passenger capacity?
i. Please advise the number of: Closed Cars: Open Cars: Passenger Cars:
j. How long is the ride?
k. Please describe passenger safety controls:
l. Please advise as to how many years of experience each engineer has:
Name Years of Experience
m. Does applicant own or lease any miniature trains? .............................................................................. Yes No
GL-APP-33g (10-17) Page 3 of 4
5. Receipts:
a. Does applicant sell any items?.............................................................................................................. Yes No
If yes, describe:
b. Estimated annual receipts: .................................................................................................................... $
c. Estimated rental receipts: ...................................................................................................................... $
d. Estimated retail receipts: ....................................................................................................................... $
6. Supervision:
Please describe the nature of the adult supervision provided while any ride or device is in use:
7. List states in which applicant operates:
8. Total number of employees:
9. Does applicant have a training program? ............................................................................................... Yes No
10. Does risk engage in the generation of power, other than emergency backup power, for their
own use or sale to power companies?.................................................................................................... Yes No
If yes, please describe:
11. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
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. (Not applicable in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY,
OH, OK, OR, RI, TN, VA, VT or WA.)
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may
include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance
company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for
the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an
insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addi-
tion, an insurer may deny insurance benefits if false information materially related to a claim was provided by the appli-
cant.
GL-APP-33g (10-17) Page 4 of 4
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insur-
er files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a fel-
ony of the third degree.
NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be pre-
sented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any
agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or state-
ment as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or
commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal
insurance which such person knows to contain materially false information concerning any fact material thereto; or con-
ceals, 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.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be sub-
ject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of
insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against
an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading infor-
mation is guilty of a felony.
NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents
a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties un-
der state law.
FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA 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. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
NEW YORK OTHER THAN AUTOMOBILE 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 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.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an active owner, partner or executive officer)
PRODUCER’S SIGNATURE: DATE:
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AMUSEMENT PROGRAM SUPPLEMENTAL GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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