Inflatable Insurance Questionnaire

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

IndividualPartnershipCorporationOther (specify)Other
FEIN:
(Jumping Pillows, Jumping Pads, Bouncy Houses, Bouncy Slides, Bouncy Castles, Moonwalks)
GENERAL INFORMATION
1. Describe your operations including a complete list of activities. Please attach a flier if available.

1a. Please complete table:

2. Are you a member of the IIP & GA (International Inflatable Products and Games Association)?

YesNo

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

4. Other items rented: (e.g. Tents, Chairs, snow cone machines, etc.) Include gross sales.

5. Other operations: (e.g. Concessions, games, etc.) Include gross sales for each:

4/5 Additional description area if needed
6. (NOT APPLICABLE IN MO) Has any policy or coverage ever been declined, cancelled or non-renewed?

YesNo

Rows	Yes	No
Do you rent inflatables? (If yes, attach a copy of the rental agreement)
If yes, a) Does Rental Agreement have a Hold Harmless Clause?
If yes, b) ) Do you set up the equipment?
If yes, c) ) Is the equipment tethered or secured?
If yes, d) Is supervision provided during rental use?
If yes, e) Are the rules and capacity limitations clearly posted on the equipment?
If yes, f) Do inflatables have signs clearly indicating age, height, size, capacity requirements?
If yes, g) When used outdoors, are there procedures to suspend use during inclement weather?

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

Rows	Yes	No
1a. On prospective employees and volunteers?
1b. On existing employees and volunteers?

Rows	Yes	No
4a. Abuse and Molestation?
4b. How to recognize the signs of abuse?
4c. What to do if an individual reports someone molested him/her?