ࡱ>  bjbjO O -a-as,Elllll$Pt<GP!((!(!(!s0t0L31(FFFFFFF$ITLFl 7,s0 7 7Fll(!(! G??? 7bl(!l(!F? 7F??:C,WD(!P bo9D mFG0G)D.HMS;HMWDHMleD[1r2?34d[1[1[1FFm=,[1[1[1G 7 7 7 7HM[1[1[1[1[1[1[1[1[1 2:  FORMCHECKBOX  Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258  FORMCHECKBOX  Scottsdale Indemnity Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258  FORMCHECKBOX  Scottsdale Surplus Lines Insurance Company Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 1-800-423-7675 Fax (480) 483-6752 www.scottsdaleins.com Amusement Program Supplemental General Liability Application (Complete in addition to ACORD General Liability Application) Name of Applicant:  FORMTEXT       Website Address:  FORMTEXT       Location Address:  FORMTEXT       E-mail Address:  FORMTEXT       Phone Number:  FORMTEXT       1. Description of operation:  FORMTEXT      Number of years in operation:  FORMTEXT       Years of experience in this field:  FORMTEXT       2. Schedule of Amusements (owned or leased): Name and Type of AmusementNo.AgeManufacturerCapacityMaximum Operating SpeedReceipts FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT      FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT      a. Does the applicant have any animal rides or animal exposures?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please describe:  FORMTEXT      b. For batting cages, are participants required to wear protective headgear?  FORMCHECKBOX  Yes  FORMCHECKBOX  No c. For paddle boats: Are U.S. Coast Guard approved life preservers provided and required for each passenger?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are paddle boat renters required to sign hold harmless agreements in the applicants favor?  FORMCHECKBOX  Yes  FORMCHECKBOX  No d. For carriages, sleighs or hayrides, are passengers driven on public streets or roads?  FORMCHECKBOX  Yes  FORMCHECKBOX  No e. For hot air balloon rides, are balloons tethered?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, maximum height of balloon:  FORMTEXT       ft. f. For lazer tag centers, is center on more than one level?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please describe:  FORMTEXT      g. Does applicant own or lease any inflatable amusement devices?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please describe:  FORMTEXT      3. Mechanical Rides: a. Do rides have signs clearly marking age, height and size limitations?  FORMCHECKBOX  Yes  FORMCHECKBOX  No b. Describe the height and type of fencing required for spectator safety:  FORMTEXT      c. Are all rides inspected?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please provide details of the inspection process:  FORMTEXT       Who Completes the Inspections?Frequency of Inspection?Are Inspection/Maintenance Logs Maintained? FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT    4. Scenic Trains: a. How often is the train maintained and inspected?  FORMTEXT       b. How often are the tracks maintained and inspected?  FORMTEXT       c. Are tracks shared with other trains?  FORMCHECKBOX  Yes  FORMCHECKBOX  No d. What is the maximum speed of the train?  FORMTEXT       e. How many times do the tracks cross streets/roads?  FORMTEXT       f. Are traffic safety devices in place at each street/road crossing?  FORMCHECKBOX  Yes  FORMCHECKBOX  No g. Are engineers subject to drug and alcohol testing?  FORMCHECKBOX  Yes  FORMCHECKBOX  No h. What is maximum passenger capacity?  FORMTEXT       i. Please advise the number of: closed cars:  FORMTEXT       open cars:  FORMTEXT       passenger cars:  FORMTEXT       j. How long is the ride?  FORMTEXT       k. Please describe passenger safety controls:  FORMTEXT      l. Please advise as to how many years of experience each engineer has: NameYears of Experience FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      m. Does applicant own or lease any miniature trains?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 5. Receipts: a. Does applicant sell any items?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, describe:  FORMTEXT       b. Estimated annual receipts? $ FORMTEXT       c. Estimated rental receipts? $ FORMTEXT       d. Estimated retail receipts? $ FORMTEXT       6. Supervision: Please describe the nature of the adult supervision provided while any ride or device is in use:  FORMTEXT      7. List states in which applicant operates:  FORMTEXT       8. Total number of employees:  FORMTEXT       9. Does applicant have a training program?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 10. Does risk engage in the generation of power, other than emergency back-up power, for their own use or sale to power companies?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please describe:  FORMTEXT      11. Does the applicant have other business ventures for which coverage is not requested?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, explain and advise where insured:  FORMTEXT      This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the information contained herein shall be the basis of the contract should a policy be issued. 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(Not applicable to Oregon). NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Notice To Florida Applicants: Any person who knowingly and with intent to injure, defraud, or deceive any in-surer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Notice To Maine Applicants: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. NEW YORK OTHER THAN AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. APPLICANT S NAME AND TITLE:  FORMTEXT       APPLICANT S SIGNATURE: Date:  FORMTEXT       (Must be signed by an active owner, partner or executive officer.) 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Arial Narrow5..[`)TahomaA$BCambria Math"3hGѓ%P%P)%xx0],], 2qHX ?uQ2!xx <Amusement Program Supplemental General Liability ApplicationGLS-APP-33g (6-11) DONNA HALL Kari Monjaras  Oh+'0, DP p |  @Amusement Program Supplemental General Liability ApplicationGLS-APP-33g (6-11) DONNA HALLNormalKari Monjaras3Microsoft Office Word@F#@ bG@4C@ b%՜.+,08 hp  Nationwide InsuranceP], =Amusement Program Supplemental General Liability Application Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry F  bData W1Table\MWordDocumentSummaryInformation(DocumentSummaryInformation8CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q