Bungee Trampoline Application

1. General Business Information

Enter the basic insured details exactly as they should appear on the policy.

Business Info

Effective Date From *

Effective Date To *

Named Insured *

DBA

FEIN / SS #

Mailing Address *

Phone Number *

Contact Person *

Web Page

Email *

Years in Business *

Total Estimated Gross Receipts

2. Bungee Trampoline Information

Provide details about your bungee trampoline units.

Equipment Details

Storage Location *

Number of Bungee Trampolines *

Bungee Trampoline Units — Complete for Each Unit

List each bungee trampoline unit with its manufacturer, year, dimensions, and pole height.

How Many	Manufacturer / Model	Year Made	Trampoline Dimensions	Support Pole Height

2b. Bungee Replacement Equipment

Complete for each piece of replacement equipment — bungee cords, poles, jumping surfaces, etc.

Replacement Parts

List all replacement equipment (bungee cords, poles, jump surfaces). This is separate from the main unit table above.

Equipment Type	Manufacturer	Size / Model Type	# on Hand	Age of Oldest	Replacement Frequency	Date Last Replaced

Trampoline Surface & Jumping Details

Maximum jumping height capacity *

Age of jumping surface on each trampoline

3. Safety, Supervision & Restrictions

Answer all questions about operator training, user restrictions, supervision, and inspection procedures.

Safety & Control

Harness & Cord Procedures

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

Yes No

Are all attendants trained on manufacturer specifications for fitting harnesses?

Yes No

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

Yes No

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

Yes No

User Restrictions

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

Yes No

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

Yes No

Minimum age / Maximum age

Minimum weight (lbs) / Maximum weight (lbs)

Minimum height (inches) / Maximum height (inches)

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

Supervision

Inspection & Authority

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

Yes No

Do you inspect all the equipment daily?

Yes No

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

Yes No

How long are records of inspections maintained?

Date of last inspection, inspecting authority, and any applicable certificate / inspection #

Describe the experience of the person(s) in charge of inspection and supervising use

Site & Set-Up

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

Fixed site only Moved site to site

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

Yes No

Do you fully test and inspect the equipment after each set up?

Yes No

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

Yes No

How long do you retain the records of testing and inspection after each set up?

4. Waivers, Padding & Clearances

Waiver practices, padding, and structural clearance details.

Site Set-Up

Waiver Practices

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

Yes No

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

Yes No

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

Yes No

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

Yes No

Padding & Clearances

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

Yes No

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

Yes No

What is the perimeter clearance maintained around each attraction?

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

5. Submission Checklist & Supporting Documents

Confirm all required items and attach supporting documents.

Documents

Required Checklist — Please confirm each item:

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

Attach files

Waivers, loss runs, safety rules, inspection records (PDF, JPG, PNG, DOC)

Upload Inspection Records

6. Review Your Application

Verify all information before proceeding to sign.

Review

Please review your answers carefully. Use Back to make changes, or Next to proceed to the signature step.

7. Warranty, Declaration & Signature

Complete after reviewing the application above.

Final Step

By completing this application, the applicant understands that coverage consideration relies on the truthfulness and completeness of the information submitted, including all attachments and supporting 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 on the 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 & the certificate/policy shall BECOME NULL AND VOID. Warranties will survive a certificate/policy if issued.

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, 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.

Print Name of Applicant *

Title *

Digital Signature *

Sign above using mouse, trackpad, or touch.

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

Bungee Trampoline Application

1. General Business Information

2. Bungee Trampoline Information

2b. Bungee Replacement Equipment

3. Safety, Supervision & Restrictions

4. Waivers, Padding & Clearances

5. Submission Checklist & Supporting Documents

Required Checklist — Please confirm each item:

6. Review Your Application

7. Warranty, Declaration & Signature

Warranty

Fraud Warning

✅ Application Submitted Successfully!