Special Event Liability Application

*Required
Company Information				Paper Version
Company Name
First Name*
Last Name*
Address*
City*
State*
Zip*
Daytime Telephone Number*
Mobile Telephone Number
Fax Number
Your Email Address*
Your Website Address (If none, supply us with a flyer of your event)
Years Experience*
Are you a Non-Profit Organization?*
Who, if anyone, referred you to us?*
For Insurance Agents & Brokers Only: Brokers Name
General Information
Is Event Indoors or Outdoors?*
Name of Event*
Type of Policy*(Promoter, Artist, Venue, Production, Special Event, etc.)
Event Date(s)*
Total Number of Shows / Performances*
Event Times*
Desired Effective Date of Policy (Load-in Date)*
Load-out Date *
Desired Expiration Date of Policy (Usually 1 day after Load-out date)*
Detailed Description of Event (If there are any live performances, list all artists along with the type of music performed.)*
Location Capacity*
Estimated Daily Attendance (Spectators) *
Estimated Total Attendance (All days)*
If this event has been held before, what was the actual total attendance
If There are Any Live Performances, or Athletes, Do You Want Participants Covered*
Estimated Number of Participants
Describe Participants (Example: Band Members, Theater Cast, Soccer Participants, etc.)
Admission Charge for this event*
Number of Non-Food Vendors/Exhibitors*
Number of Food Vendors*
Number of Attractions (games, etc.)*
Budget/Cost for this event*
Estimated Gross Receipts
Venue/Site Information
Name of Venue/Location*
Will your event take place at more than 1 location? (If yes, please include a schedule in the Notes section below)
Venue Mailing Address
City*
State*
Zip
Telephone Number
Fax Number
Contact Person (First & Last Name)
Contact Person Email Address
Venue Additional Insured Wording (Found in your rental agreement)
What Per Occurrence Liability Limit does the venue require? (Found in your rental agreement)*
What Aggregate Liability Limit does the venue require? (Found in your rental agreement)*
Who is supplying security?*
Is security armed?*
Type of Security (Uniform, peer group, ushers, etc.)*
How Many of Each?*
Type of Seating (folding, bleachers, etc.)*
Seating is*
Underwriting Information
List anyone else you need to name as Additional Insured on your policy
Describe First Aid/Medical arrangements*
Are you responsible for parking?*
Is parking lot attended?
Will event include any Stunts, Pyrotechnics, Aircraft, Pools, Lakes or other bodies of water, Car Races, Rides, Moon Bounces, Inflatable Activities, or other Hazardous Activities?*
If yes, please explain
Who is responsible for setting up the stage and temporary seating?*
Who was your previous insurance company*
Premium paid*
List all previous claims (Last 5 years)*
Would you like an annual quote insuring all of the events you have planned for the next 12 months? If yes, you must complete and submit a schedule of the events you want insured.
Liquor Liability Option If you are selling alcohol (including beer & wine), consider protecting yourself against liquor liability claims.
Are you directly selling, or sharing income from the sale of alcohol?
If yes, what name is the liquor license filed under?
Who is serving (Location, Caterer, You, etc.)?
Estimated Total Liquor sales?
Describe procedures & safeguards for preventing the serving of alcohol to minors & intoxicated persons
Non-Owned & Hired Auto Option Consider this option if your employees are using their vehicles on company business or you're renting/borrowing vehicles. You also have the option to insure against physical damage to the rented/hired vehicles.
Number of vehicles rented or borrowed?
Number of vehicles used by employees?
Total cost to rent vehicles
If physical damage to rented vehicles is desired, what is the maximum value of any one vehicle?
What is the total value of all vehicles?
Property (Equipment & Contents) Option
Description of Equipment
Describe protection, security at principal location
Value of Owned Equipment
Value of Rented Equipment
Value of Office Contents
Total Values
Describe any prior losses/claims
Workers' Compensation Option Usually required by state law for employers who have 1 or more employees. Premium is based on payroll for the period of time the policy is in force. Owners / officers are excluded from coverage.
Payroll Company
Payroll by job duties	# Full Time	# Part Time	Total Payroll
In Office Only (Clerical)
Outside Salespersons
Performers/Musicians
Production Crew
Motion Picture Production (film/video crew)
Full names and titles of all owners or officers. Coverage will be excluded for these persons.
Employers' Federal I.D. Number
Staff, Volunteers & Spectator Accident Medical Option For a quote on "no fault" medical reimbursement ("goodwill insurance"), choose this option. You are able to cover employees under this policy but it is not a substitute for workers' compensation coverage (see above).
Number of Staff
Number of Volunteers
Do you want Spectators included in the coverage?
Weather Insurance Option If your event would be affected by bad weather, consider buying Rain / Snow / Wind / Lightning coverage
Coverage Date
Coverage Times	From To
Policy Limit
Include the following perils	Rain: Lightning: Snow: Wind:
List any additional dates and times in the Additional Notes section below
Event Cancellation Insurance Option Broader than Weather Insurance, it can cover cancellation due to damage to the venue, terrorism, non-appearance of an artist, etc.With the information below, we will be able to give you a general idea on pricing. However, for a firm quote, a more detailed application will be required.
Is the event indoors?
If no, is the performance area under a cover?
Would bad weather cause cancellation of your event?
Budgeted Total Gross Revenue
Budgeted Total Expenses
Net Income (Revenue less Expenses)
Prize Insurance Option Attract crowds to your event. Increase ticket sales. Generate publicity. Offer additional reasons for people to attend. Half-Court Shots, Picking the winning envelope, scratch off tickets, putting contests, Hole-in-One Contests. Let us help you design a promotion. With the information below, we will be able to give you a general idea on pricing. However, to receive a firm quote, a more detailed application will be required.
Describe to us the type of prize promotion you want including the value of the prize.
Application Notes/Additional Information
Application Warranty & Instructions I HEREBY WARRANT AND CONFIRM THAT THE ABOVE INFORMATION, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT, AND FURTHER CERTIFY THAT I HAVE READ ALL OF THE QUESTIONS AND ANSWERS OF THIS APPLICATION. I UNDERSTAND THIS APPLICATION IS A REQUIREMENT FOR COVERAGE, A PART OF THE CONTRACT AND EVIDENCE OF MY ACCEPTANCE OF THIS INSURANCE, AND ANY FALSIFICATION OR MISREPRESENTATION WILL BE DEEMED A BREACH OF CONTRACT, VOIDING ALL INSURANCE COVERAGE. IT IS UNDERSTOOD AND AGREED THAT THE COMPLETION OF THIS APPLICATION SHALL NOT BE BINDING EITHER TO THE PROPOSED INSURED OR THE COMPANY UNTIL ACCEPTED BY THE COMPANY OR COMPANIES IN WRITING.
Name of person acknowledging Warranty*
Date of acknowledgment*
For Insurance Agents & Brokers Only
Your Company Name
First Name
Last Name
Address
City
State
Zip
Daytime Telephone Number
Mobile Telephone Number
Fax Number
Your Email Address