Fillable HAUNTED ATTRACTIONS APPLICATION (Kinsale Insurance)

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HAUNTED ATTRACTIONS APPLICATION (Kinsale Insurance)

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The HAUNTED ATTRACTIONS APPLICATION (Kinsale Insurance) form is 5 pages long and contains:

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  • 88 check-boxes
  • 25 other fields

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Page 1 of 5
HAUNTED ATTRACTIONS APPLICATION
COMPLETE IN ADDITION TO ACORD APPLICATIONS.
ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
1) DATE:
2) APPLICANT NAME:
3) MAILING ADDRESS:
4) STREET ADDRESS (If different):
5) CITY, STATE, ZIP CODE:
6) Description of Operations:
7) Website Address: www.
1) Operating Dates:
2) Beginning: Ending: Hours of Operation:
3) Estimated Gross Receipts:
4) General Admission:
5) Parking Receipts:
6) Concessions (including food and beverage – excluding alcohol):
7) Alcoholic beverage (if any):
Other:
8) Estimated attendance per day: Estimated Square Footage:
APPLICANT’S INFORMATION
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 5
1. Our volunteers or employees cannot physically touch the customers during their skits. Yes No
2. Our volunteers or employees are trained to deal with the public in this environment. Yes No
3. Employees or volunteers are 18 years or older. Yes No
4. We provide adequate medical or first aid services on site during operating hours. Yes No
5. Public parking areas are well lit and supervised. Yes No
6. Volunteers or employees keep walking surfaces clear of debris or obstacles. Yes No
7. We prohibit the patrons from touching or interacting with the displays or skits. Yes No
8. Displays do not include working power tools (e.g., saws, drills) or electrical shock Yes No
machines or tricks.
9. There are no low hanging ropes, nooses, props or displays crossing the customers path. Yes No
10. We do not permit the public to bring pets (dogs or other animals) on the premises. Yes No
11. We do not use flammables, pyrotechnics, fireworks, firecrackers, or flash explosives. Yes No
12. We do not allow smoking on premises. Yes No
Type of Building or Structure: Free standing structure Interconnected mobile trailers Temporary/Portable structures
1. The building meets all state, local, or governing agency life safety, fire and occupancy statutes, Yes No
or requirements. (e.g., NFPA 101, Local Building Codes etc.)
2. The building has been inspected and approved for occupancy by the local fire authority. Yes No
3. Employees or volunteers are present throughout the facility during operating hours to monitor Yes No
or assist patrons as they tour the displays.
4. Uneven walking surfaces, steps, or flights of stairs are supervised by a designated employee or Yes No
volunteer during operating hours.
5. Is the haunted house more than one story? Yes No
6. Do patrons use slides to move from one level to another? Yes No
7. Are there moving or sinking floors, or moving or sinking stairs? Yes No
1. The unit is propelled by: Tractor Animal Other motorized vehicle (explain)
2. The unit was specifically designed, and constructed by others to transport people. Yes No
3. The unit has permanently mounted seats for riders. Yes No
EMPLOYEE/VOLUNTEER SPECIFICATION – PROVIDE DETAILED INFORMATION FOR ALL “NO” RESPONSES
HAUNTED HOUSE SPECIFICATIONS
HAUNTED HAYRIDE/WAGON SPECIFICATIONS
Page 3 of 5
4. The unit is properly equipped to prevent riders from falling. (guard rail, seat backs, handrails etc). Yes No
5. Wheel wells are properly covered/protected to prevent accidental contact with any moving parts. Yes No
6. You do not permit patrons to exit the unit before the entire trip is completed. Yes No
7. You do not permit employees/volunteers to board the wagon after it has left the start area. Yes No
8. Operators are over 18 years of age and qualified operators of the unit. Yes No
9. The unit does not operate on, or cross any public street, road, highway, or thoroughfare. Yes No
1. The maze was created by cutting pathways through growing crops. Yes No
2. If the maze is not cut through growing crops but consisting of walls made from of bales, you Yes No
meet or exceed minimum thickness and stabilizing requirements for this type of construction.
3. All walking areas are level and free of uneven surfaces. Yes No
4. Your employees or volunteers monitor activities within the maze from a tower, bridge, platform, Yes No
or other vantage point.
5. There are adequate exits throughout the maze in the event patrons elect to exit without completing. Yes No
6. You have a rodent/pest control program in place. Yes No
1. Your employees or volunteers guide patrons through the trail. Yes No
2. Patrons may not leave the trail during the walk. Yes No
3. Patrons may not leave the group without completing the entire attraction. Yes No
4. All walking areas are level and free of uneven surfaces. Yes No
5. Patrons are not permitted to climb on interact with skits or displays. Yes No
6. Your Employees or Volunteers may not touch patrons as they walk past their display. Yes No
7. There are no hanging ropes, or empty nooses in any of the displays. Yes No
8. You have a rodent/pest control program in place. Yes No
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA,
NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN, AND
WYOMING APPLICANTS: In some states, 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, for the purpose of misleading, conceals information concerning any fact material
thereto, may commit a fraudulent insurance act which is a crime in many states.
HAUNTED MAZE SPECIFICATIONS
HAUNTED WALKING TRAIL SPECIFICATIONS
Page 4 of 5
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete or misleading facts or information 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 policyholder or claiming with regard to a settlement or award payable for insurance proceeds shall be
reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: 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 addition, an insurer may deny insurance benefits if false information materially
related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit
is a crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance 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.
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 subject 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 denial of insurance benefits.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
NOTICE TO NEW MEXICO 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 civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 and the stated value of the claim for
each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she 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: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim for the
proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an application for
insurance or statement of a 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 the person to criminal and civil penalties.
NOTICE TO TENNESSEE 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 include imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA 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 include imprisonment, fines and denial of insurance benefits.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the above
statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit any material
facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective date of
any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn based upon
such changes at our sole discretion.
Page 5 of 5
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this application
and made a part of this application.
Applicant: Title:
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
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HAUNTED ATTRACTIONS APPLICATION (Kinsale Insurance)

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Completed 31 January 2021

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