Mechanical Bull Insurance Quote Form

General Information

First Name *

Last Name *

Corporate or LLC Name *

FEIN # or DBA Name

Mailing Address *

City *

State / Province *

ZIP / Postal Code *

Location Address *

Location City, State, Zip Code *

Primary Phone Number *

Cell Phone Number *

Fax Number

E-Mail Address *

Date Business Started Under Current Ownership *

/

Current Insurance

Have you been previously insured? *

Current Insurance Provider

Nature of Business

Please select the option that best describes the nature of your operation *

If other, please describe other business operations:

Mechanical Bull Information

Is Mechanical Bull hydraulic drive or electric? *

Hydraulic Drive
Electric

Is Mechanical Bull located at a fixed site or mobile? *

Fixed Site
Mobile

Please check all venues where Mechanical Bull will be operated

Bars or Taverns
Private Parties
Rodeos
Carnivals or Fairs
Competitions
Other - please see below

Please describe other venues of operation

Revenue Breakdown

Revenue from misc rentals and supplies (Mobile Game Shows, Carnival Type Game Booths, Cash Cubes, Video Games, Pin Ball Machines, Skee or Skeet Ball, Putting Challenge, Foosball, Air Hockey, Pop A Shot* *

*Also: Football Challenge, Pool Tables, Spin Art Pictures, Oriental Name Writing, Rice Art Jewelry, Candle/Sand/Candy Art

*Also: Wax Hands, DJ/Sound/Video Equip., Photo Booths, Disco Ball, Old TIme Photos, Table/Yard Bowling, Simulators w/o motion, Hi-Striker, Batting Cage Game with Tee, Advertising Signs

Revenue from simple mechanicals (Trikes, small & large mechanical devices, Bumper Boats and Cars, Trackless Trains *

Revenue from interactive inflatables (air filled amusements and devices such as Slides, Bounce Houses, Combo Bounce Houses with Slides, Obstacle Courses) *

Revenue from interactive devices (direct interaction between participants such as Paint Ball, Dunk Tanks, Mini Golf Driving Ranges, Putting Greens* *

*Also: Boxing Games, Lazer Tag, Hay Rides, Simulators with Motion, Velcro Wall

Revenue from Physical Activity Devices (Euro Bouncers/Bungee, Rock Walls WITH Auto Belay, Jousts, Jacobs Ladder, Bungee Runs *

Revenue from physical activity devices II (Rock Walls WITHOUT Auto Belay Systems, Electric Bulls, Go Carts, Haunted Attractions, Batting Cage with Pitching Machine *

Revenue from physical activity devices III (Orbitrons with motors (only) Sumo Suit, and simiilar - Air Bots, etc.) *

Revenue from entertainment services (Clowns, DJ, Magicians, etc.) *

Are they subcontracted or Employees?

Subcontracted
Employees

Are background checks done?

Yes
No

If subcontracted, do you get copies of their certificate with limits equal to yours?

Yes
No

Revenue from food and beverage products and rentals (Hot Dog Cookers, Nacho/Popcorn Machines, Snow Cone/Frozen Drink Machines, Chocolate Fountains, Warm Pretzel/Cotton Candy Machines, Ice Cream Sundae Bar *

Revenue from tables, tents and chairs *

Revenue from restaurants & snack bars *

Revenue from catering *

Revenue from party planning *

Revenue from other - Please Describe *

Revenue from subcontracted devices (please also describe) *

If subcontracted, do you get copies of their certificate with limits equal to yours?

Yes
No

Revenue from Hydraulic Bull, Orbitron without Motor, Zorb balls, Water Balls, Hamster Balls *

TOTAL REVENUES *

Rockwall Information

Do you have a rockwall? *

Is the Rockwall Supervised by a trained operator at all times?

Yes
No

Is the tool loop cut off from the safety harness?

Yes
No

When the Rockwall is not is use, how and where do you store it?

How often are the cables replaced?

Is the Rockwall manual or auto belay?

Risk Assessment

Please provide details to any "Yes" answers

Do you have an employee safety program? *

Do they sign documentation after said program?

Yes
No

Do you provide written operating instructions for scheduled equipment? *

Do you utilize an inspection sheet for inflatable and mechanical amusement rides? *

Is there a formal ride/equipment maintenance program including maintenance logs? *

Is equipment stored inside? *

Is your yard secured? *

Please select the formal safety training that applies:

SIOTO
ROAR
AIMS
Red Cross
NAARSO
IALEI
Commonwealth of PA
None of these

Risk Management

Please provide details to any "Yes" answers

Is there a rental agreement between you and your client? *

Percentage of time your rental agreement was used without alteration

Percentage of time a customer provided contract is used *

Percentage of customers you do business with that are individuals *

Percentage of customers you do business with that are corporations and/or schools *

Percentage of customers you do business with that are governmental *

Number of owners & officers active in business *

Total number of staff during the year (DO NOT include owners) *

Number of Full Time Employees: *

Number of Part-time Employees *

Number of Seasonal Employees *

Equipment Rental Information

Do you rent any of your amusement devices/rides without operators/attendents? *

If yes, what percentage is without operators?

Do you have a customer training program? *

If yes, do they sign documentation after said program?

Do the amusement devices/rides have signs clearly marking age, height, or size limitations? *

Is any equipment left over night at the site where it was used? *

Do you use the manufacturer's checklist for the set up and use of the equipment? *