Form PC321 (AR-100) "Amusement Ride Certificate of Inspection/Reinspection" - Texas

What Is Form PC321 (AR-100)?

This is a legal form that was released by the Texas Department of Insurance - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2005;
  • The latest edition provided by the Texas Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form PC321 (AR-100) by clicking the link below or browse more documents and templates provided by the Texas Department of Insurance.

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Download Form PC321 (AR-100) "Amusement Ride Certificate of Inspection/Reinspection" - Texas

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PC321 (AR-100) | 1005
 Print
AMUSEMENT RIDE CERTIFICATE OF INSPECTION/REINSPECTION
Required for each ride, pursuant to Texas Occupations Code, Chapter 2151, Amusement Ride Safety Inspection and Insurance Act and 28 Texas
Administrative Code §§5.9004 -- 5.9014, Amusement Ride Rules, along with a $40 per ride filing fee and picture of the ride in an operable state
taken at the time of the inspection.
Own
er/Operator
Information
Owner/Operator (Insured)
Address
Telephone Number (
)
Amusement Ride Information
Amusement Ride Name
Serial Number
Manufacturer
Date Manufactured
Date of Last Overhaul or Renovation
Date of Last
Inspection
(previous)
Amusement Ride Classification:
A
( )
Ride designed primarily for use by children 12 years of age or younger with a fixed location
B
( )
Ride other than Class A
Amusement Ride Inspector Shall Complete the Following Statement
I hereby certify that the above described Amusement Ride was inspected/reinspected in an operable state and meets the standar ds and
requirements of
Insurance Company and the inspection requirements as set forth
in 28 TAC §§5.9001 -- 5.9014 and in Chapter 2151, Texas Occupations Code.
INSPECTOR: DO NOT USE STAPLES ON PICTURES. PICTURE PAGE MUST HAVE BUSINESS NAME / RIDE NAME / SERIAL NUMBER AND DATE PICTURE IS TAKEN.
Signature of Inspector
Date
Name and Title of Inspector
Inspection Company
Address
Telephone Number (
)
Cell Number: (
)
Authorization of the Insurance Company
Name and Title (Print)
Signature of Authorized Insurance Company Representative
Telephone Number
TDI Amusement Ride Validation Stamp
TDI Inspection Sticker Number
Texas Department of Insurance | www.tdi.texas.gov
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PC321 (AR-100) | 1005
 Print
AMUSEMENT RIDE CERTIFICATE OF INSPECTION/REINSPECTION
Required for each ride, pursuant to Texas Occupations Code, Chapter 2151, Amusement Ride Safety Inspection and Insurance Act and 28 Texas
Administrative Code §§5.9004 -- 5.9014, Amusement Ride Rules, along with a $40 per ride filing fee and picture of the ride in an operable state
taken at the time of the inspection.
Own
er/Operator
Information
Owner/Operator (Insured)
Address
Telephone Number (
)
Amusement Ride Information
Amusement Ride Name
Serial Number
Manufacturer
Date Manufactured
Date of Last Overhaul or Renovation
Date of Last
Inspection
(previous)
Amusement Ride Classification:
A
( )
Ride designed primarily for use by children 12 years of age or younger with a fixed location
B
( )
Ride other than Class A
Amusement Ride Inspector Shall Complete the Following Statement
I hereby certify that the above described Amusement Ride was inspected/reinspected in an operable state and meets the standar ds and
requirements of
Insurance Company and the inspection requirements as set forth
in 28 TAC §§5.9001 -- 5.9014 and in Chapter 2151, Texas Occupations Code.
INSPECTOR: DO NOT USE STAPLES ON PICTURES. PICTURE PAGE MUST HAVE BUSINESS NAME / RIDE NAME / SERIAL NUMBER AND DATE PICTURE IS TAKEN.
Signature of Inspector
Date
Name and Title of Inspector
Inspection Company
Address
Telephone Number (
)
Cell Number: (
)
Authorization of the Insurance Company
Name and Title (Print)
Signature of Authorized Insurance Company Representative
Telephone Number
TDI Amusement Ride Validation Stamp
TDI Inspection Sticker Number
Texas Department of Insurance | www.tdi.texas.gov
1/1