Inflatable Jumper Application Form

Please fill out the following form. You cannot save data typed into this form.
Please print your completed form if you would like a copy for your records.
(*) indicate required fields

Company Name *   Contact Name *  
Number of Employees   FEIN/TAX ID *  
Currently insured *   State *  
Address *   Business Type *  
City *  
Zip Code *  
Phone *   Fax  
Email   Website Address  
Proposed effective date *   Calender Gross annual revenue*  
Date business started under current ownership *   Calender Title(position)  
Type of operation *  
Any policy or coverage declined, canceled or non-renewed during the prior 3 years:
Brief description of the business operations/activities*:

Inventory List

Inflatables and Mechanical rides
Attach Separate Inventory List Below If Needed
Items (including non-inflatable) Sizes
Length x Width x Height		     Price
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Non Inflatable Items (Tables, Chairs etc.)


Items (including non-inflatable) quantity     Price
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$

Coverages applying for
Standard Liability
  • $2,000,000 General Aggregate (Other Than Products/Completed Operations)
  • $2,000,000 Products/Completed Operations Aggregate
  • $1,000,000 Personal/Advertising Injury
  • $1,000,000 Each Occurrence
Texas Applicants only
  • $2,000,000 General Aggregate (Other Than Products/Completed Operations)
  • $2,000,000 Products/Completed Operations Aggregate
  • $2,000,000 Personal/Advertising Injury
  • $2,000,000 Each Occurrence

Please Include Your Rental Agreement

Please Include Inventory list

Please Include Loss Run


Insured Date Calender