Bungee Trampoline Application

1. General Business Information

The ACORD 125 commercial insurance application must also be completed in addition to this supplemental application.

Carrier Form Basis

Effective Date From *

Required field.

Effective Date To *

Required field.

Years in Business *

Required field.

Named Insured *

Required field.

DBA

FEIN / SS # *

Required field.

Contact Person *

Required field.

Mailing Address *

Required field.

Phone Number *

Required field.

Email *

Required field.

Web Page

Total Estimated Gross Receipts *

Required field.

Named Insured Entity Type

2. Bungee Trampoline Information

Complete the storage, count, dimensions, jumping capacity, and equipment schedule details for all bungee trampoline equipment.

Inventory + Schedule

Storage Location *

Required field.

Number of Bungee Trampolines *

Required field.

Maximum Jumping Height Capacity *

Required field.

Age of Jumping Surface of Each Trampoline *

Required field.

Equipment Schedule

Please complete for each piece of equipment.

Equipment Type	Manufacturer	Size / Model Type	# on Hand	Age of Oldest One	Replacement Frequency	Date Last Replaced	Year	Trampoline Dimensions	Support Pole Height	Action

Keep your internal inventory names and models consistent.

3. Safety Restrictions & User Control

These questions are taken from the carrier's bungee trampoline safety section.

Safety Questions

Do you always fit harness to the size of each person?

Are all attendants trained on manufacturer specifications for fitting harnesses?

Do you always adjust the bungee cords according to manufacturer recommendations for the weight and height of each user?

Are all attendants trained on manufacturer requirements for bungee cord adjustment?

Do you require users to comply with age, weight, and height restrictions?

How do you verify weight/height when user size visually appears to be over the limit?

User Restriction Limits

Minimum Age

Maximum Age

Minimum Weight

Maximum Weight

Minimum Height

Maximum Height

Does your waiver indicate any user restrictions noted by the manufacturer?

Do you always maintain a one-to-one ratio of attendant supervision for each person on a trampoline?

If no, please describe supervision procedure.

Do you always restrict users to one at a time per trampoline?

Were all attractions inspected and found satisfactory by a state or local authority?

Date of last inspection, rating authority, and applicable certificate / inspection #

4. Inspection, Setup & Operating Controls

Document daily inspection, setup, testing, movement between sites, waiver procedure, and protective padding details.

Operational Controls

Is there a barrier or fence around the attraction to prevent pedestrian or observation traffic in the jumping area?

Is access to area around attraction restricted to attendants and one user per attraction?

Are user restrictions, warnings, and safety signs clearly posted by the entrance to the attraction?

Do you inspect all the equipment daily?

Do you document your inspections with a written checklist and findings?

How long are records of inspections maintained?

Describe the experience of the person(s) in charge of inspection and supervising use of the bungee jump trampolines.

Is this equipment always attended when set up?

Is this equipment located in one site or moved from site to site?

Do you always set up and take down the equipment if moved from the site?

Do you fully test and inspect the equipment after each setup?

Do you use a written checklist to document your testing and inspection after each setup?

How long do you retain records of testing and inspection after setup?

Do all users sign and date a waiver and release document? (attach a copy)

Are minors required to have a parent or legal guardian sign the waiver?

Does your waiver require the signing party to represent in writing that they are over 18?

Do you require a legibly printed name of the signing party on your waiver?

Is secured padding provided over the trampoline springs and frame perimeter?

Is the flooring beneath and surrounding the perimeter of the attraction padded?

What perimeter clearance is maintained around each attraction?

What is the height clearance between the highest point of the attraction and the ceiling?

5. Submission Checklist

Attach the supporting items noted in the carrier checklist below.

Checklist + Files

Checklist Items

5 year currently valued loss runs No Known or Reported Loss Letter if operating with no prior insurance Copy of Rental Agreement / Waiver Safety Rules Pictures of signage with Hold Harmless wording

Upload Supporting Documents

Loss runs, waiver copy, safety rules, signage photos, or other supporting files.

Upload Inspection / Carrier Documents

Inspection certificates, authority records, or other compliance documents.

Warranty

It is hereby understood and agreed that if insurance is issued by virtue of completing this application and any applicable supplemental applications, the insurance is only issued in reliance on the applicant’s warranty of answers to the questions above and on any such supplemental applications. If, at the time a certificate/policy is issued and any of the above warranties is in any respect incorrect, including claims or gross receipts, the coverage afforded under the certificate/policy shall, without notice to the applicant, immediately and automatically cease and the certificate/policy shall become null and void. Warranties will survive a certificate/policy if issued.

6. Document Review

Review the application before signing. Use the button below to generate a summary sheet.

Review & PDF

Please confirm that all business information, safety procedures, operating controls, and checklist items are complete and accurate before proceeding to signature.

Click Generate Review to compile the entered information.

7. Signature & Fraud Warnings

The signature section, warranty reliance statement, and fraud warnings are included below.

Final Step

Applicant Signature

Print Name of Applicant *

Required field.

Title

Date *

Required field.

Signed By Email

Signature of Applicant (Mandatory)

Draw your signature with mouse or touch.

Applicant Confirmation

I hereby warrant, represent, and confirm that to the best of my knowledge all information provided is complete, true, and correct. I understand the insurance company will rely on the information contained in this form and all other information submitted.

Fraud Warnings

General 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 for the purpose of misleading conceals information concerning any fact material thereto, may commit a fraudulent insurance act which is a crime and subjects such person to criminal and civil penalties in many states.

California

Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Colorado

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.

District of Columbia / Louisiana

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.

Florida / Oklahoma / Kansas

False, incomplete, or misleading information in an insurance application may constitute a felony or fraudulent insurance act and may result in prosecution, fines, denial of insurance, or civil penalties.

Maine / Tennessee / Virginia / Washington / Maryland / New Hampshire / New York

Providing false, incomplete, or misleading information for the purpose of defrauding an insurance company may be a crime and may result in imprisonment, fines, denial of benefits, rescission, or civil penalties. Refer to the original carrier form for full state-specific wording where required.