Haunted Attractions Quote ApplicationPlease 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 50% Applicant InformationInsured Name* Mailing AddressStreet* City* State*StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code* Event Name/AddressStreet* City* State*StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code* Website Address* Applicant is* Individual Corporation Partnership Joint Venture Contact First Name* Contact Last Name* Phone*FaxEmail Address* Event InformationEvent Description:*Attach any promotional material Drop files here or Select files Max. file size: 256 MB. Haunted Hayride* Yes No Effective Date* End Date* Date Business Established* Is the Insured (owner) of this facility CHAOS (Certified Haunted Attraction Operator Seminar) certified?* Yes No If yes, please attach copy of certification (certification is required a minimum of every other year)* Drop files here or Select files Max. file size: 256 MB. 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*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 If using hired security, are certificates of insurance obtained?* Yes No Are first aid facilities provided?* Yes No Describe* 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* 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* Special Effects and Devices:*Stairs (unlighted)* Yes No Slides* Yes No If you have a slide inside your haunted attraction, it will be excluded from our policies, as we do not have any Carriers that will provide coverage for this exposure.Fire or Open Flame* Yes No For warming purposes? If not, explain* +Moveable Floors* Yes No Pictures required with application* Drop files here or Select files Max. file size: 256 MB. +Sinking Floors* Yes No Pictures required with application* Drop files here or Select files Max. file size: 256 MB. +Spectator Touching* Yes No Spectator Touching is NOT permitted and NOT coveredAre Employees / Volunteers allowed to touch Patrons?* Yes No +Electrical Shock Devices* Yes No 9Volt battery operated only+Live Animals* Yes No +Live Insects* Yes No +Live Reptiles* Yes No Smoke Machines* Yes No Bubble Machines* Yes No Strobe Lighting* Yes No Drive-Through Haunts?* Yes No Zombie Paintball?* Yes No Live actors or targets?* Describe any other events, attractions, taking place during the operation of the Haunted House (DJ’s, bands, zombie paintball, hay rides, etc.)*+Some exclusions include, but are not limited to: Patron Touching, Rat Racers/Rat, Livestock Coverage, Electrical Shock Devices, Rollers Water Activities.Any additional Insureds being requested?* Yes No Provide Name, Address and Reason:*Insured listed as Additional Insured on Certificate of Insurance from Outside Vendors?* Yes No Escape Room?* Yes No *If yes, supplemental application needed. **If there are moving or sinking floors, please provide pictures with your submission.Is there a separate charge and attendance for this?* If yes, supplemental application needed. If there are moving or sinking floors, please provide pictures with your submission. Drop files here or Select files Max. file size: 256 MB. Laser Tag?* Yes No Lighted Exit Signs?* Yes No How many lighted exit signs?* Applicant HistoryDescribe applicant's experience with haunted houses including years, numbers, and dates:*Premium and Loss Record for the Last Five YearsPremium 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 Select files Max. file size: 256 MB. Describe details of losses/incidents for the past 3 years: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.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. Please review all the following fields to ensure your information is accurate, then scroll down to the bottom of the page and click "SUBMIT".{all_fields}Section to be Completed by the Producer/Broker/AgentAgent Name Agent Signature Date CAPTCHA