Haunted Attractions Quote Application

Applicant Information

Insured Name*

Mailing Address

Street*

City*

State*

Zip Code*

Event Name/Address

Street*

City*

State*

Zip Code*

Website Address*

Applicant is*

Contact First Name*

Contact Last Name*

Phone*

Fax

Email Address*

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*

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

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

Fire or Open Flame*

Yes
No

For warming purposes? If not, explain*

+Moveable Floors*

Yes
No

Pictures required with application*

Drop files here or

Max. file size: 256 MB.

+Sinking Floors*

Yes
No

Pictures required with application*

Drop files here or

Max. file size: 256 MB.

+Spectator Touching*

Yes
No

Spectator Touching is NOT permitted and NOT covered

Are 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

Max. file size: 256 MB.

Laser Tag?*

Yes
No

Lighted Exit Signs?*

Yes
No

How many lighted exit signs?*

Applicant History

Describe applicant's experience with haunted houses 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:

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.

Step 1 of 2

Applicant Information

Mailing Address

Event Name/Address

Event Information

Applicant History

Premium and Loss Record for the Last Five Years

Section to be Completed by the Producer/Broker/Agent