Please fill in the online application form below and click on Submit Applicaton button to submit your application online.
You can download PDF version of this application if you prefer to fax or mail this application to us.
Please sign, date and fax or mail your application to

CSI Insurance Agency, Inc.
316 Maxwell Rd., Suite 100
Alpharetta, GA 30004
Fax: 678-832-4911

RENTAL COMPANY

Name of Company
Type of Organization
FEIN # (or Tax ID)
Address
City
State
Zip Code
Phone (xxx) xxx-xxxx
Fax (xxx) xxx-xxxx
Email
Website
Contact Person's Name
Years in Business
Receipts from rentals of inflatable play units
Receipts from rentals of non-inflatable play units and games
Receipts from products sold
If you are engaged in any other business please
provide name and description of the business

INVENTORY ITEMS

List all inventory items available for rental, by category indicated
(or email or fax complete list with required data)

Inflatable Play Units - List Individually
  Manufacturer of Unit Name of Unit Dimensions
(Length, Width, Height)		 Age of Unit Est. Annual Revenue
From Rentals		  
  Add
Click on or to add or remove rows

Non-Inflatable Play Units - List By Type
  Name of Unit Manufacturer of Unit # of units Est. Annual Revenue
From Rentals		  
  Add
Click on or to add or remove rows

Party Games, Cotton Candy & Fun Food, Arts & Craft - List By Type
  Name of Item # of units Est. Annual Revenue
From Rentals		  
  Add
Click on or to add or remove rows

Other Rental Items
  Name # of units Est. Annual Revenue
From Rentals		  
  Add
Click on or to add or remove rows

Other Services Provided
  Describe Service Est. Annual Revenue
From Rentals		  
  Add
Click on or to add or remove rows

INSURANCE COVERAGE AND QUESTIONS

Please answer to the following questions
Select limit of liability $300,000
$500,000
$1,000,000

Do you want to cover Theft or Damage to Equipment?

Yes No
If yes, what is the total cost of your entire Equipment inventory?
Do you maintain and operate equipment in accordance with manufacturer instructions? Yes No
Do you keep daily inspected records for a period of at least 6 years? Yes No
Do your records clearly show a unit was inspected and is ready-to-rent on the day rented? Yes No
Are you familiar with and do you comply with all regulations and local authority regarding safe use and operation of inflatable amusement equipment? Yes No
Do you always obtain a signed Rental Agreement that contains instructions for use and hold harmless and indemnity provisions? Yes No
Does your rental agreement prohibit use of inflatables by persons over the age of 15 unless the unit is designed and intended for use by adults? Yes No
Do you prohibit use by adults and children at the same time?
(Adults are persons over the age of 15 for purposes of this insurance) 		Yes No
Do you clearly and explicitly prohibit use of equipment by anyone under the influence of alcohol, drugs or any other intoxicating substance? Yes No
Do you keep a First Aid Kit on site when you are supervising the operation of equipment? Yes No
Does this application contain a complete list of all inflatable play products owned by you? Yes No
Are you engaged in any other business besides inflatable rental or operation? If yes, you must explain in detail
 Yes No
Are you properly licensed to operate or conduct this business? Yes No
Have you or any of your employees or sub-contractors been charged or convicted of any criminal offense? Yes No
Have there been any claims for injury or damages against you or any incidents that may lead to a claim against you with within past 5 years? If yes, explain in detail
 Yes No
Do you always setup or supervise the setup of the equipment you rent? If not, explain
Yes No
If you use sub-contractors, are they fully trained and provide evidence of insurance with limits of at least $300,000? Yes No
Do you monitor weather and notify customers of actions to take when indicated by weather conditions? Yes No
If manufacturer offers additional safety upgrades for units do you always install them on your units? Yes No
The following items or situations require an employee or experienced attendant
  1. Slides greater than 22'
  2. Rockwalls
  3. Mechanical Bulls, Suef Simulators and similar devices
  4. Harness bounce trampolines (non-harness trampolines will not be covered)
  5. Items used at fairs or large community events
Do you use employees or experienced attendants in these situations? 		Yes No

YOU MUST READ THIS BEFORE SIGNING BELOW

To the best of my knowledge and belief the information provided in connection with this application is true and I have not withheld any material facts.

I understand that the signing this application does not bind insurance coverage, but agree that should a contract of insurance be concluded, this application, and supplemental application or questionnaire , and the statements therein will be relied on as the basis for insurance coverage.

I understand the insurance company may obtain additional information in order to evaluate accetability for insurance, such as, but not limited to, credit reports, motor vehicle records, survey or inspectons of covered operations or prior claim experience verification. I hereby authorize the company to obtain such information.

 
Your Name:   Your Title:
Your Initials:   Date:

A copy of your rental contract, including liability waiver or indemnity and hold harmless
wording, should be emailed to IIPG@csiprotection.com or faxed to 678-832-4911 following
completion of this application