Fall Festivals Quote Application

Please answer the following questions to the best of your ability. We understand that these are estimates. If you have questions, please call us at (641) 585-0510.

Step 1 of 2

Any amusement attraction, device, activity or special event not listed on this application will not be considered or contemplated within our quote. Any amusement attraction, device or activity listed is still subject to underwriting approval. Please read our quote carefully to determine what is considered/contemplated with our quote and what amusement attraction, device or activity is excluded or not part of our quote.
Applicant Information
Insured Name*
Mailing Address
Street*
City*
State*
Zip Code*
Event Name/Address
Name*
Street*
City*
State*
Zip Code*
Website Address*
Applicant is*
- Individual
- Corporation
- Partnership
- Joint Venture
Contact First Name*
Contact Last Name*
Phone*
Fax
Email Address*
Hours of Operation:
Spring: Open?*
- Yes
- No
Days/Hours of Operation:*
Summer: Open?*
- Yes
- No
Days/Hours of Operation:*
Fall: Open?*
- Yes
- No
Days/Hours of Operation:*
Winter: Open?*
- Yes
- No
Days/Hours of Operation:*
Event Information
Event Description:*
Attach any promotional material
Drop files here or

Max. file size: 256 MB.
Haunted Hayride*
- Yes
- No
Effective Date*
End Date*
Date Business Established*
Estimated Attendance*
Last Year's Attendance*
Max Capacity at Event Location*
Price of Admission*
Estimated Gross Attraction Receipts*
Estimated Gross Attraction Receipts (Estimated Attendance x Price of Admission)
Estimated Food Receipts*
Estimated Merchandise Receipts*
Prior Year Gross Receipts*
Attendee Age Demographic*
Minimum Age*
Special Concerns for Children*
Event is Held*
- Indoors
- Outdoors
- Both
Fenced*
- Yes
- No
Crowd Control/Security Personnel*
- Ushers
- Private Security
- Off-Duty Police
How Many?*
Security Guards used?*
- Yes
- No
- Armed
- Unarmed
If using hired security, are certificates of insurance obtained?*
- Yes
- No
Is applicant named as additional insured?*
- Yes
- No
Describe procedures and protocols:*
How Many Personnel?*
Employee Type and Numbers*
Regular*
Leased*
Volunteer*
Is Workers' Compensation Coverage in Force?*
- Yes
- No
Estimated Payroll*
Will bleachers or platforms be used?*
- Yes
- No
Will they have back and side rails?*
- Yes
- No
Are food and beverages sold on the premises?*
- Yes
- No
Outside vendor?*
- Yes
- No
Food types available*
Cooking methods if cooked on site*
Alcoholic beverages served*
Is Liquor Liability policy in force?*
- Yes
- No
Is Liquor sold by 3rd party vendor?*
- Yes
- No
Is applicant named as additional insured?*
How are guests escorted?*
Lead Guides*
- Yes
- No
How many Lead Guides?*
Follow-up Guides*
- Yes
- No
How many Follow-up Guides?*
Door Monitors*
- Yes
- No
How many Door Monitors?*
Max. Group Size*
Does Insured operate Haunted House at this location?*
- Yes
- No
If so, please complete the haunted house supplement.
Is the Insured (owner) of this facility CHAOS (Certified Haunted Attraction Operator Seminar) certified?*
- Yes
- No
Please attach copy of certification*
Drop files here or

Max. file size: 256 MB.
Certification is required a minimum of every other year.
Special Effects and Devices:*
Part of a Haunted Attraction?*
- Yes
- No
Strobe Lighting*
- Yes
- No
Other Events or Attractions at the Same Site:*
+Some exclusions include, but are not limited to: Patron Touching, Rat Racers/Rat, Livestock Coverage, Electrical Shock Devices, Rollers Water Activities.
Applicant History
Describe applicant's experience with Fall Festivals including years, numbers, and dates:*
Premium and Loss Record for the Last Five Years
Premium and Loss Record for the Last 3 Years:*
For each year, please list policy period, carrier, premium, loss amount, and non-renewal or cancel.
Please attach Loss Runs from your prior Insurance Carrier(s), for the past 3 years. If this is your first year in business, please disregard. If you have been with Donat Insurance Services, LLC, for the past 3 years, please disregard.
Drop files here or

Max. file size: 256 MB.
Describe details of losses/incidents for the past 3 years:
Liability Supplement
Applicant Name*
Rides and Attractions - Do you have the following:
Petting Zoo*
- Yes
- No
Animals must be hand-led or tethered.
Type of Animals:*
Exotic or Dangerous Animals*
- Yes
- No
Animals Fenced In*
- Yes
- No
Spectator Touching*
- Yes
- No
Hand Washing Stations*
- Yes
- No
Horse-drawn Carriage Rides*
- Yes
- No
Hay Rides*
- Yes
- No
Drivers must be 25 years and over. Wagons must have 3-foot sides and must be pulled by a farm implement tractor.
Off Premises or on Public Roads*
- Yes
- No
Night Rides*
- Yes
- No
Does trail have any lighting?*
- Yes
- No
Max. % Grade at Steepest Part of Trail*

If Hay Ride Loading/Unloading Area has more than a 2% incline, it must have 2 Operators.
Operator 1 - Driver of the Tractor: MUST REMAIN IN TRACTOR AT ALL TIMES.
Operator 2 - MUST REMAIN AT REAR OF WAGON during loading/unloading time to assist patrons.
Jumping Pillow/Jump Pad--Attendant MUST be present at ALL times*
- Yes
- No
Size (# and/or feet x feet)*
How many?*
Manufacturer*
Do you make separate charges for jumping pillows?*
- Yes
- No
Please supply revenue breakout along with attendance:*
Warning Signs and Safety Rules posted/printed on pillow surface:*
Slide*
- Yes
- No
How many?*
Landing Surface*
- Grass
- Sand
- Gravel
- Dirt
- Liner
Slide Length*
- 20 ft.
- 40 ft.
- 60 ft.
- 80 ft.
Employee Attendant must be present at the top and bottom of ALL slides 60 ft. and longer.
Slide Type*
- Open
- Closed
Slide Type Comment
Cow Train Ride*
- Yes
- No
Wheel Base Requirements: Inside Wheel Base must be a minimum of 30". Outside Wheel Base must be a minimum of 39".
All Kiddie Rides/Cow Trains must be pulled by limited speed capability vehicles or low horsepower tractors.
Pumpkin Launcher*
- Yes
- No
How many?*
Pumpkin Patch?*
- Yes
- No
Pedal Cars?*
- Yes
- No
Pond*
- Yes
- No
Water Activities Excluded
Fenced In/Roped Off/Fishing*
- Fenced In
- Roped Off
- Fishing
Size*

Employee Attendant must be present at ALL times.
Playground Equipment?*
- Yes
- No
Please provide complete list of equipment:*
Corn Canon*
- Yes
- No
Camp Fires*
- Yes
- No
Size of Fire Ring*

Employee Attendant must be present at ALL times.
How many?*
What type of campfire?*
- Wood burning
- Propane
Kiddie Zip/Handle Bar Slide*
- Yes
- No
Maximum Weight Permitted is 100 lbs.
Length*
Height from Cable to Ground (ft.)*
Type*
- Sitting
- Hanging/T-Bar
Attendant Procedure for Starting and Landing of Kiddie Zip:*
Employee Attendant must be present at ALL times.
Offsite Parking?*
- Yes
- No
Please provide location address:*
Escape Room?*
- Yes
- No
If yes, please complete supplemental
Paintball Gallery?*
- Yes
- No
If yes, please complete supplemental
Trains?*
- Yes
- No
Permanent track?*
Max Speed*
Amusement Rides?*
- Yes
- No
Please provide a complete list of each ride*
Please provide photos of all amusement rides*
Drop files here or

Max. file size: 256 MB.
Mechanical Bull?*
- Yes
- No
Hay Bales / Hay Pyramid / Hay Mountain?*
- Yes
- No
Pumpkin Swing?*
- Yes
- No
Rock Wall?*
- Yes
- No
Log Jam?*
- Yes
- No
Inflatables?*
- Yes
- No
Super Mega Slide?*
- Yes
- No
How many?*
Pony Rides?*
- Yes
- No
Are ponies tethered?*
Are pony rides covered elsewhere?*
Is the applicant included as an additional insured on that policy?*
- Yes
- No
Fireworks / Pyrotechnics?*
- Yes
- No
Is applicant signing any Hold Harmless Agreement?*
- Yes
- No
Please provide a complete copy of this agreement/contract*
Drop files here or

Max. file size: 256 MB.
Any other special events?*
- Yes
- No
Please list dates and provide a description of the event:*

If yes, please fill out the Special Events Supplemental App.
**Employee attendance must be at each of the following at ALL times: campfire, hay ride, pond, kiddie zip - failure to follow these requirements could jeopardize coverage under your insurance policy.
Please list and describe any other rides or attractions previously not mentioned:*
Insurance Coverage will be written with limits of $1,000,000 per occurrence and an annual aggregate of $2,000,000. The Insured represents that the information contained in this application is accurate and that it shall be the basis of the policy of insurance. The Insured further represents that it has not withheld any information which would have affected the company’s decision to offer coverage. If the insured has withheld any such information with intent to defraud or give false information to the company, the Insured understands that its coverage may be voided. The Insured further understands that its failure to disclose any information in its possession, which may lead to a claim, will relieve the insurance company of any obligation under the policy.
Additional Insureds
Relationship
Name
Address
Relationship
Name
Address
Relationship
Name
Address
*SOME EXCLUSIONS INCLUDE, BUT ARE NOT LIMITED TO: PATRON TOUCHING, RAT RACERS / RAT ROLLERS, LIVESTOCK COVERAGE, ELECTRICAL SHOCK DEVICES, WATER ACTIVITIES.
Insured Signature*
Date*
Electronic Signature Agreement*
- By checking this box I acknowledge that the information I have entered is accurate and understand that the field above constitutes as my electronic signature.
Revenue Audit
I understand that written policies are subject to audit.
We understand both the attendance and receipt values are estimated values. With that, we strongly encourage you to give the most accurate estimate as possible. By doing so, it allows us to provide you with a quote that is as reflective of your needs as possible. In addition, all policies are subject to an audit upon expiration. Therefore, providing the most realistic estimate as possible, not only allows us to provide the most accurate quote, but will also aide in reducing the possibility of a large discrepancy in these estimates when audited, which could potentially result in additional premium charges.

SUBMIT

Fall Festivals Quote Application

Step 1 of 2

Applicant Information

Mailing Address

Event Name/Address

Event Information

Applicant History

Premium and Loss Record for the Last Five Years

Liability Supplement

Additional Insureds

Section to be Completed by the Producer/Broker/Agent