Rock Wall Application

1. General Business Information

Enter the basic insured details.

Business Info

Effective Date From *

Effective Date To *

Named Insured *

DBA

FEIN / SS #

Mailing Address *

Phone Number *

Contact Person *

Web Page

Email *

Entity Type *

Years in Business *

Total Estimated Gross Receipts

2. Rockwall Information

Provide locations, manufacturer, configuration, and maintenance details (in carrier paper-app order).

Equipment Details

Locations

List each location where the rockwall operates.

Location #	Location Address

When the Rockwall is Not in Use, How and Where Do You Store It?

How Often Are the Cables Replaced?

When Was Your Rockwall Manufactured?

What is the Height of the Rockwall? (ft) *

What is the Name of the Rockwall?

3. Submission Checklist

Confirm all required items and attach supporting documents.

Submission Checklist

Required Checklist

5 Year Currently Valued Loss Runs Copy of Rental Agreement/Waiver Safety Rules Pictures of Signage with Hold Harmless Wording No Known/Reported Loss Letter

Upload Equipment Photos

Upload Training Records

Upload Supporting Documents

Upload Additional Photos

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.

4. Warranty & 5. Signature

Complete after reviewing the application above.

Final Step

4. Warranty

(Applies to all parts of this application and attachments submitted)

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.

5. Signature

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.

Print Name of Applicant *

Title *

Signature of Applicant (Mandatory) *

Sign above using mouse, trackpad, or touch.

Date * Declaration * I confirm that the information provided in this application is complete, true, and correct to the best of my knowledge.