Agritainment Insurance Questionnaire

Agritainment Insurance Questionnaire
Applicant's Name:*
Address:*
Mailing Address
Address (cont):*
Mailing Address - continued
Contact:*
Email*
Telephone:*
Website
Fax:
Applicant is:

IndividualPartnershipCorporationOther (specify)Other
Current Carrier:
Expiration Date:
Limits: ($)
Premium: ($)
Deductible: ($)
Limit of Liability Desired:

$300,000$500,000$1,000,000
GENERAL INFORMATION - Please complete all questions in this section.
1. Describe your operations including a complete list of activities. Please attach a flier or provide website address if available.
2. Are operations year-round or seasonal?
3. Are participants required to sign any releases of waivers? (If yes, please attach a copy of the waivers.)

YesNo
4. Do you have an operations/procedure manual?

YesNo
5. Do you have an employee training program?

YesNo
6. What is the minimum age requirement for your employees?
7. Are releases signed by all applicants? (Please attach a copy of the release.)

YesNo
8. Do you ever hire sub-contractors/independent contractors that carry their own insurance?

YesNo
8a. If yes, please describe:
8b. If yes, are certificates of insurance provided?

YesNo
8c. Do subcontractors name you as additional insured on their policy?

YesNo
8d. Total Cost ($)

9. Do you use any mobile equipment?

YesNo
9a. Check all that apply:

ATVsGolf CartsSnowmobilesBobcatsCranesTractorsHorse Drawn WagonHorse Drawn SleighsOther
9b. What is the use of this equipment? Check all that apply:

Transporting peopleOfficials/Staff OnlyTransporting Supplies or EquipmentOperated/Driven by PublicOther
9c. Where is the equipment stored when not in use?
9d. Who is responsible for the insurance of the mobile equipment?
10. What precautionary measures have been taken in the event of a medical emergency or injury?
11. Briefly describe what security measures will be taken. Include the number of security personnel and the name of the firm providing the security
12. Do you serve alcohol at your operation?

YesNo
12a. If yes: Who is providing the liquor liability coverage?
12b. If yes: Who is providing the security in the area where the liquor is being served?
12c. Will you allow others to serve alcohol at this event? (If yes, Certificates of Insurance are required.)

YesNo
Note: If Liquor Liability coverage is desired, please contact Kevin Morency for a quote. (Liquor Liability will only be available if we provide the General Liability for your agritainment operation.)

ACTIVITIES AND AMENITIES OFFERED
1. Children’s Play Area

YesNo
1a. If yes, please describe what’s included (e.g., corn pit, giant tire for climbing, etc.):

2. Do you offer any of the following activities?

	Yes	No
2a. Pedal Cars
2b. Pumpkin and/or Corn Cannons. Provide photos.
2c. Slingshots (pumpkin, watermelon). Provide photo.
2d. Stocked-Pond Fishing
2e. Bike Rental
2f. Greenhouses
2g. Climbing Wall

3. Carnival Rides (Please note: Your policy will exclude amusement rides.)

YesNo
3a. If yes, please describe:
4. Do you manufacture and sell any food or beverages, including concession stands or restaurant?

YesNo
4a. If yes, please list:
4b. Describe the cleaning and sanitation schedule:
4c. Do you serve or sell any meat/seafood products?

YesNo
4ci. If yes, do you have written procedures for proper handling, preparing, and serving of raw meat/seafood?

YesNo
4d. Has the local Department of Health inspected your operation? (If yes, provide a copy of the most recent inspection.)

YesNo
4e. Have you ever been cited for any health code violations?

YesNo
4ei. Briefly describe and provide copy of health code violations.
5. Do you allow food trucks to provide food and beverages at your operation?

YesNo
5a. If yes, please describe. Provide a copy of food truck license and health department inspection.
5b. If yes, do you obtain a certificate of insurance from the food vendor operation?

YesNo
6. Retail Operations on Site?

YesNo
6a. If yes, please describe:
7. Other (describe):

8. Please indicate gross sales for each segment of your operations:

	Amount ($)
Admission Fees
Rides (Fees in addition to admission, such as: Pony Rides, Jumping Pillows, Trains, etc.)
Pumpkin Sales
Christmas Tree Sales
Pick-Your-Own Sales
Restaurant/Concession Sales on Site
Food Sales on Site
Retail Sales on Site
Liquor Sales
Other (Describe below)
TOTAL SALES - current year
Estimated Total Receipts for next 12 months

8a. Other (describe)
9. Location(s), Dates of Operation, Expected Attendance and Hours of Operation: (List additional locations on separate page)
Location 1: Address and Activities
Location 2: Address and Activities

9a. Please provide the following information about your locations.

	Acreage	Own or Lease	Dates Open	Expected Daily Attendance	Hours of Operation
Location 1
Location 2

HAY, SLEIGH, WAGON, OR TRAIN RIDES

1. Do you offer any of the following activities? Please provide photo(s).

	Yes	No
1a. Hay Rides
1b. Sleigh Rides
1c. Pony Rides
1d. Train Rides (Barrel, Trackless, Railed)

2. Describe the wagon(s)/sleigh(s)/train(s) used in the ride (number owned/rented, construction material, wheel type, seating capacity, age):
3. Is there a maintenance/inspection program in place for vehicles/trains/wagons?

YesNo
3a. If yes, please describe program include how often each ride is checked:
3b. Do you maintain a safety log?

YesNo
4. How is each wagon, train, sleigh drawn (horse, tractor)?
5. If horses are pulling wagons, please describe the safety program for passenger loading/unloading:
6. Are there any night rides?

YesNo
6a. If yes, what type of lights, etc. are used?
7. Describe the experience of the employees:
8. What type of training/orientation takes place?
9. Are patrons required to remain seated through the ride? (Please provide photo of safety signage - Example: "Stay Seated...No Standing Until Operator States Ride Has Stopped")

YesNo
10. Are rules and regulations clearly posted?

YesNo
11. In addition to the driver, how many employees are used for each wagon for supervision?
12. Is there any driving on or crossing of public roads?

YesNo

PETTING ZOO
1. Do you offer a petting zoo to the public? (If Yes, please answer the following questions.)

YesNo
1a. Please list animal and number of each:
1b. What is the handler’s experience with the animals?
1c. Is each animal examined by a veterinarian at the start of each season?

YesNo
1d. Do you have emergency procedures and equipment on site for animal bite? (First aid kit available.)

YesNo
1e. Do you have a safety precaution sign at the entrance? (Please provide picture of sign.)

YesNo
1f. Is the petting zoo area fenced? (two fences needed – outer fence may be snow or construction fence)

YesNo
1g. Do you allow visitors to feed animals? (Dry feed only) If yes, provide picture of "Don't eat animal feed" sign by feeding station.

YesNo
1h. Do you have a hand sanitizing station with a sign requiring people to sanitize their hands after petting the animals? (Please provide picture of sign.)

YesNo
PICK-YOUR-OWN OPERATIONS
(See separate sections for Pumpkins and Christmas Trees, if applicable.)
Note: Pick-Your-Own coverage will only be available if we provide the General Liability for your agritourism operation.
1. Do you offer u-pick operations to the public? (If Yes, please answer the following questions.)

YesNo
1a. List items you offer in public u-pick operations.
1b. Are these items grown at location(s) listed on page 2, Question 4?

YesNo
1b. If no (or obtain additional items from other sources), please provide list of items, vendor(s) and Certificate(s) of Insurance.
1c. Do customers use ladders or elevated platforms?

YesNo
PUMPKIN FARM TOURS AND SALES
1. Do you offer pumpkin farm visits and sales? (If Yes, please answer the following questions.)

YesNo
1a. Are these items grown at location(s) listed on page 2, Question 4?

YesNo
1a. If no (or obtain additional pumpkins from other sources), please provide list of items, vendor(s) and Certificate(s) of Insurance.
1b. Please provide a detailed description of the tour of your operation.
CHRISTMAS TREE SALES
1. Do you offer Christmas trees for sale? (If Yes, please answer the following questions.)

YesNo
1a. Are these items grown at location(s) listed on page 2, Question 4?

YesNo
1a. If no (or obtain additional trees from other sources), please provide list of items, vendor(s) and Certificate(s) of Insurance.
1b. Are customers allowed to cut or trim trees?

YesNo
1c. If yes, tools provided to cut trees-check all that apply:

Hand SawsPower SawsHatchet or AxeOther
1d. Do you load trees on/in customer vehicles?

YesNo
1e. Check if applicable:

Sledding/Tubing HillIce SkatingSkiingOther

INFLATABLES (Jumping Pillows, Bouncy Houses/Slides, Etc.)
1. Do you offer inflatables? (If Yes, please answer the following questions.)

YesNo

1a. Please complete table:

	Amount
Receipts ($)
Number of Units
Number of Attendants

1b. Has the proposed coverage been purchased before?

YesNo
1b. If yes, Current Carrier
1b. If yes, Limit of Liability ($)
1c. Describe any losses or incidents in past three years:
1d. Are all inflatables properly anchored/secured/tied down?

YesNo
1e. Type of flooring in inflatables area)
1f. Do inflatables have signs clearly indicating age, height, size, capacity requirements?

YesNo
1g. Are all inflatables manned by an operator/attendant?

YesNo
1h. Are your inflatables inspected by the state and/or your employees?

YesNo

1i. Equipment Inspection

	Yes	No
1i. Is the equipment inspected after each use?
If yes, a) Are inspection records maintained?
If yes, b) Are time period inspection records kept?

1j. Renting Inflatables

	Yes	No
1j. Do you rent inflatables? (If yes, attach a copy of the rental agreement)
If yes, a) Are they rented with operators/attendants?
If yes, b) Do you deliver the inflatables?
If yes, c) Do you set up the inflatables?
If yes, d) Do you tear down inflatables?
If yes, e) Do you use the manufacturer’s checklist for the set up and use of the equipment?
If yes, f) When used outdoors, are there procedures to suspend use during inclement weather?
If yes, g) Does Rental Agreement have a Hold Harmless Clause?

1k. Please complete chart below or provide a separate schedule with the following information:

	Manufacturer	Type of Inflatable, Slide	Age/Height	Attraction Dimension	Capacity (Max)	Height of side
Item 1
Item 2
Item 3
Item 4

HAUNTED HOUSE
1. Do you offer a haunted house? (If Yes, please answer the following questions.)

YesNo
1a. The haunted house is:

InsideOutside

Please answer the following questions:

	Yes	No
1b. If outdoors, is the area fenced?
1c. Are any candles used?
1d. Is there any human contact?
1e. Is there any use of live animals?
1f. Are there any moving floors, walls or steps?
1g. Are there any slides?
1h. Are bleachers or platforms used?
1i. Are smoke effects used?
1j. Are extension cords used?
1k. Is the haunted house inspected by the fire department prior to use?
1l. Are there age restrictions/limits?
1m. Is first aid available?

1n. If yes to any of above questions, please explain:

Please complete table:

	Enter info below
1o. Maximum number of individuals in house at one time:
1p. Number of days open:
1q. Hours of operations:
1r. Anticipated number of people to go through the haunted house:
1s. Estimated gross receipts:
1t. Price of admission:

1u. Any special handling of young children?

YesNo
1v. Do you use lead or follow-up guides?

YesNo
1w. Door monitors?

YesNo
1x. Are exit signs clearly marked and illuminated?

YesNo
1y. If transportation is used to move attendees to the house, please explain the type of transportation, the distance they will travel, and how it is powered:
1z. Type of building:
1aa. Usual use:
1bb. Number of stories:
1cc. Age of building:
1dd. Square footage of building open to the public:
1ee. What type of divisions/walls?
1ff. Describe lighting on stairs:
1gg. If private security is used, how many guards?

N/AHow many guards?

ZIP LINE OPERATIONS
1. Do you offer a zip line? (If Yes, please answer the following questions.)

YesNo
2. Who designed the course?
2a. Were Certificates of Insurance obtained?

YesNo
3. Who constructed the course?
4. What year was the course originally built?
4a. How many zip lines does the course consist of?
4b. What is the maximum height of the course?
4c. What is the length of the course?
4d. How long does the ride last?
4e. Does the course contain any suspended bridges?

YesNoHow many?
4f. Are any portable elements used (i.e. challenge walls, etc.) or unique obstacles?

YesNo
5. Have you made any additions or alterations to the course since it was built?

YesNo
5a. If yes, list date of change, type of alteration (or element added), and construction vendor name:
6. How often is the course inspected?

DailyMonthlyAnnuallyOther
6a. Who inspects course?
6b. Date of last course inspection (month/year)
6c. Do you maintain a written log documenting inspections and related equipment?

YesNo
6d. Have you made recommended improvements to course since last inspection?

YesNoN/A
6e. Do you perform daily visual inspections of the course and equipment?

YesNo

Please answer the following:

	Enter info below
7. Total number of participants anticipated in coming year:
a. Anticipated receipts:
b. Percentage of Participants - under 18 years old
c. Percentage of Participants - over 18 years old
d. Minimum Age:
e. Maximum Age:
f. Minimum Weight:
g. Maximum Weight:
h. How are weight requirements checked/enforced?

8. Are all participants required to wear gloves and helmets?

YesNo
9. Are participants harnessed prior to advancing to the top of the zip line platform?

YesNo
10. Does your course require participants to hand brake?

YesNo
10a. If yes, please describe instructions given to participants:
10b. If no instruction given, what method is used to stop participant?
11. Is the course rented to outside groups or individuals? (If yes, please provide copy of rental contract.)

YesNo
11a. If yes, do you provide supervision?

YesNo
11b. Gross receipts from leased periods:
12. Do you require all participants to sign a waiver of liability? (If yes, please attach a copy.)

YesNo
12a. If yes, do all minors have their parents or guardians sign their forms?

YesNo

MINIATURE GOLF
1. Do you offer miniature golf? (If Yes, please answer the following questions.)

YesNo

2. Please answer the following:

	Receipts	Number of Attendants	Total Number of Holes	Number of Courses
Enter info:

3. Do fountains and waterfalls have ground fault interrupters in place?

YesNo
4. Is appropriate safety warning and rule/regulation signs posted at club rental counter and/or hole #1?

YesNo
GOLF DRIVING RANGE
1. Do you offer a golf range? (If Yes, please answer the following questions.)

YesNo
2. Receipts:
2a. Number of Stalls/Tee Boxes:
3. Are there partitions between stalls/tee boxes?

YesNo
3a. Describe partitions between tee boxes.
4. Maximum one (1) person allowed per tee box?

YesNo
5. Are there any two-tier driving platforms? (If yes, please provide picture.)

YesNo
5a. If yes, describe barriers.
6. Are other attractions exposed to the range?

YesNo
6a. Explain:
7. Do all ranges face away from the public access areas?

YesNo
8. Is the range fenced in?

YesNo
9. Is there a safety zone of at least 30 feet between the range, parking lots, roads, etc.?

YesNo
WEDDINGS
1. Are weddings performed on your premises? (If Yes, please answer the following questions.)

YesNo

2. Please provide the following information:

	Enter info below
2. How many weddings per year?
2a. Maximum number of guests
3. Are receptions held on site?
3a. Number of receptions per year

PROPERTY INSURANCE
1. Do you need Building and/or Content Coverage?

YesNo

1a. If yes, please complete chart below or provide a separate property schedule with the following information:

	Building Age	Building Construction	Building Limit ($)	Content Limit ($)
Building 1
Building 2

2. Do you need Equipment Coverage?

YesNo
2a. If yes, total value to insure for?

Replacement CostActual CostTotal Value ($)

2b. If yes, please complete equipment schedule below or provide a separate equipment schedule with the following information:

	Year	Make	Model	Value to Insure For ($)
Item 1
Item 2
Item 3

COMMERCIAL AUTOMOBILE INSURANCE
1. Does the business title any automobiles or other operating vehicles in the business name?

YesNo
2. Is insurance coverage needed for owned automobiles?

YesNo

2a. (If yes, complete chart below or provide a separate vehicle/fleet schedule with following info.)

	Vehicle Make	Vehicle Model	Cost New ($)	Year
Vehicle 1
Vehicle 2
Vehicle 3

2b. If yes, limits desired:

	Amount ($)
Limit of Liability
Comprehensive Deductible
Collision Deductible

3. Do any of the employees, owners or officers drive personally owned automobiles/other vehicles in the course of their work?

YesNo
3a. If yes, how many?
3b. Do you verify they have liability coverage?

YesNo
3c. Limits? ($)
UMBRELLA AND WORKERS' COMPENSATION INSURANCE
1. Do you need a Commercial Umbrella?

YesNo
1a. If yes, limit of liability needed? ($)
2. Do you need Workers Compensation? (If yes, please contact Kevin Morency.)

YesNo
SIGNATURE
The information I have provided is true and accurate to the best of my knowledge. I have not willfully concealed or misrepresented any material fact(s) or information. I understand completion of this questionnaire does not compel the company to provide coverage.
Signature

Clear
Or Enter Your Full Name as Signature:
Date:
Questions? 877-244-9090
Kevin Morency | kmorency@morencyinsurance.com

Morency & Associates Inc.
141 New Shackle Island Rd, Hendersonville, TN 37075
Fax: 615-452-6580

https://agritainmentinsurance.com/
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