220APP0220 Page 1 of 5
Applicant Name: Agent’s Name:
Mailing Address: Mailing Address:
Location Address: Proposed Effective Date:
From: 12:01 A.M. Standard Time at
the address of the Applicant
1) Years in Business:
2) Experience of Owners/Principals:
If this is a new operation, please provide details on owners’/principals’ prior experience (attach resumes):
3) Type of Trampoline:
Wall to Wall Bungee
Stand Alone Tramp Track
4) Manufacturer/Brand of trampoline systems:
5) Are the trampoline systems fully compliant with ASTM and NFPA regulations:
a. ASTM F1159: Standard practice for design and manufacture of patron-directed
amusement devices. Yes No
b. ASTM F2375: Standard Practice of design, manufacture and installation of safety
netting around tops of trampolines and foam pits. Yes No
c. NFPA 701: Minimum flame resistance for materials from which pads and trampolines
are made. Yes No
6) Are safety signs posted at your facility and at the points of entry? Yes No
7) What is the average ratio of participants to employee supervision?
8) What is the minimum ratio of participants to employee supervision?
9) Is every participant required to sign a liability waiver? Yes No
10) Are parents or legal guardians required to sign liability waivers on behalf of all minors? Yes No
220APP0220 Page 2 of 5
11) Was your liability waiver written or reviewed by an attorney to confirm compliance with all
applicable laws and regulations in the state where your park is located? Yes No
If yes:
When was it written?
When was it last reviewed by an attorney?
12) What is the minimum participation age?
13) Are minors permitted to jump with parent/guardian? Yes No
14) Are participants separated by age and experience? Yes No
15) Are instructors given to jumpers prior to each session? Yes No
How are they given? Verbally Video Written
16) How are employees trained?
17) Are background checks performed on all employees? Yes No
18) Is at least one supervisor who is trained and certified in first aid on duty at all times? Yes No
19) Is all equipment inspected prior to each jump session? Yes No
20) Do you repair your own trampoline equipment? Yes No
If yes:
a. Name of contractor performing repairs (attach a separate sheet if needed):
b. Are they insured? Yes No
c. Are certificates of general liability insurance required? Yes No
d. Do the certificates list you as an additional insure? Yes No
e. Do you execute written contracts with the contractor including indemnification clauses
in your favor? Yes No
21) Have you modified the trampoline system? Yes No
If yes, how?
22) Are competitive jumping lessons taught? Yes No
23) Are there devices/activities other than trampolines in the facility? Yes No
If yes, please select:
Basketball Courts
Mechanical Bull
Ninja Courses
Rock Climbing Walls
Zip Lines
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24) Are jumpers separated from participants of other devices/activities listed above? Yes No
25) Any apparatus hanging from ceiling in jumping area? Yes No
If yes, complete the following:
a. Distance from jumping area to apparatus: ft
b. Distance from jumping area to ceiling: ft
26) Do entrances and platforms have impact-absorbing material on all surfaces within 48 inches of
device frames (floor, patron barriers, banisters, rails, etc.)? Yes No
27) Is barrier netting at top of all platform barriers? Yes No
28) Is barrier or gate used to prevent unauthorized access to devices? Yes No
29) Does a redundant fall-through protection device exist under all jump surfaces? Yes No
30) Is impact-absorbing matting completely covering springs and device frames? Yes No
31) Is impact-absorbing matting attached to jump surfaces and secured to device frames? Yes No
32) Total square footage of trampolines:
33) Do you own or lease the premises? Own Lease
34) Square footage of building:
35) Do you have fire alarms? Yes No
36) Do you have an automatic sprinkler system? Yes No
37) Are all building/facility exists in compliance with applicable building codes? Yes No
38) Hours of Operations:
Weekdays: From To Weekends: From To
39) Are overnight camps/lock-in’s sponsored or allowed? Yes No
40) Does the park host sports leagues of any kind? Yes No
41) Total Estimated Sales for upcoming year and prior four years:
a. Projected Sales Upcoming Year: $
b. Actual Current Year: $
c. Actual First Prior Year: $
d. Actual Second Prior Year: $
e. Actual Third Prior Year: $
42) Do you sell food or non-alcoholic beverages? Yes No
If yes, total food and non-alcoholic beverage sales (if any)? $
43) Do you sell or serve alcoholic beverages, or allow consumption of alcoholic beverages on your
property? Yes No
44) Are child care services provided by you or others at your property? Yes No
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Please note the following documents are material to completion of the application and must also be attached:
Liability Waiver
Court Maintenance Program
Court Rules and Safety Guide
Operating Instructions for Each Device
Employee Training Guide
Management Guide
Business Plan
Additional Information:
Applicable in AL, AR, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully)* presents a false or
fraudulent claim for payment of a loss or benefit or 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. *Applies in MD only.
Applicable in CO: 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 policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds
shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Applicable in FL and OK: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a
statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (of the
third degree)*. * Applies in FL only.
Applicable in KS: Any person who knowingly and with intent to defraud, presents, causes to be presented, 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 statement 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 conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent
insurance act.
Applicable in KY, NY, OH and PA: 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 to exceed five thousand dollars and the
stated value of the claim for each such violation)*. *Applies in NY only.
Applicable in ME, TN, VA, and WA: 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 and denial
of insurance benefits. *Applies in ME only.
Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy
is subject to criminal and civil penalties.
Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by
submitting an application containing a false statement as to any material fact may be violating state law.
Applicable in PR: Any person who knowingly and with the intention of defrauding presents false information in an
insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any
other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction,
shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten
thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating
circumstances [be] present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating
circumstances are present, it may be reduced to a minimum of two (2) years.
Applicable in all other 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 conceals for the purpose of misleading, information concerning any material fact, commits a fraudulent
insurance act, which is a crime and may also be subject to civil penalty.
I/We understand that this is an application for insurance only and that the completion and submission of this
Application does not bind the Company to sell nor the applicant to purchase this insurance. I/We hereby declare
that the above statements and particulars are true and I/we agree that this Application shall be the basis for any
contract of insurance issued by the Company in response to it.
Electronic Signature of Applicant or Authorized Representative:
Title: Date:
If you prefer not to return the questionnaire with an electronic signature, please print and sign.
220APP0220 Page 5 of 5
click to sign
click to edit
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