*Required
 
Company Information
 
Company Name  
First Name*  
Last Name*  
Address*  
City*  
State*  
Zip*  
Daytime Telephone Number*  
Mobile Telephone Number  
Fax Number  

Your Email Address*

 
Your Website Address  
Years Experience*  
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 Event*(Camp, Team, Bike Race, Triathlon, Football, etc.)

 

Event Date(s)*

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*  
Number of Participants Daily*  

Total Participants (all days combined)*

How many are under the age of 18?*

 
Age of Youngest Participant*  
Age of Oldest Participant*  
For multiple day events, are the participants the same persons each day?*  
Number of Spectators (All days)*  
Admission Charge $*  
Budget/Cost for this event $*  
Estimated Gross Receipts $*  
Venue/Site Information
 
Name of Venue/Location*  
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)  
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*  

What Per Occurrence Liability Limit does the site require? (Found in your permit/ rental agreement)*

 
What Aggregate Liability Limit does the site require? (Found in your permit/rental agreement)*  
Underwriting Information
 
List anyone else you need to name as Additional Insured on your policy (Include name and complete mailing address)  
Describe First Aid/Medical arrangements*  
Are Participants Required to Sign a Waiver of Liability?*  

Will event include any Stunts, Pyrotechnics, Aircraft, pools, lakes or other bodies of water, Car Races, Rides 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:

 
Estimated number of annual events  
Average number of participants per event  
Total number of participants for all events  
Tell us about your next 5 events:    
Event Name Type of Event Event Dates Number of Participants  
 
 
 
 
 

Liquor Liability Option

If you are selling alcohol (including beer & wine), consider protecting yourself against liquor liability claims.

 
Are you selling, or sharing income from the sale of alcohol?  
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. Only bodily injury liability in case of an accident is covered, not damage to the vehicles.

 
Number of vehicles rented or borrowed?  
Number of vehicles used by employees?  
Total cost to rent vehicles: $  
Any vehicles seat more than 10 passengers?  
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  

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 athlete, 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 event 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 athletes to your event. Increase ticket sales. Generate publicity. Offer additional reasons for people to attend. World Record quests, Hole in One attempts, 1/2 Court Basketball Shots, 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