Haunted House Liability Application
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5Haunted House Liability Application
Cossio Insurance Agency
864-688-0121
Fax: 864-603-2348
P.O. Box 5987, Greenville, SC 29606
Section 1: APPLICANT INFORMATION
Company Name:
Business Name:
Contact Name:
Address of Applicant:
City:
State:
Zip:
Phone Number:
Email Address:
Website Address:
DOB:
FEIN/SS#:
Section 2: GENERAL INFORMATION
How did you hear about us?
...
1. Date(s) of Event:
Time(s):
2. Name of Haunted House:
3. Name of Facility:
4. Location of Haunted House:
5. Description of Haunted House:
6. Has this Event been held in the past by the Applicant?
Yes
No
If Yes, for how many Years?:
7. Estimated Attendance Per Day?
8. # of Tickets Printed?
9. # of Tickets Sold to Date?
10. Price of Admission?
11. Estimated Gross Receipts?
12. Estimated Total Payroll?
# of Employees & Volunteers
Total number of participants: 12 & younger
13-15
16-18
19 and older
13. What are the Limits of Liability Requested?
General Aggregate: $
Products Aggregate: $
Each Occurrence: $
Personal/Adv Injury: $
Fire Damage: $
Medical Payments: $
13. Is this Event Located Indoors or Outdoors?
Indoor
Outdoor
If Outdoors, Is the Area Fenced or Enclosed?
Yes
No
14. Please describe in detail all “Special Effects”
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