NAMED INSURED
*
APPLICANT'S NAME
*
STREET ADDRESS
*
CITY
*
STATE
*
ZIP
*
PHONE
*
FAX
EMAIL
*
DESCRIBE APPLICANT'S ROLE AND RESPONSIBILITY IN EVENT
ADDITIONAL INSURED 1
NAME AND ADDRESS
ADDITIONAL INSURED 2
NAME AND ADDRESS
ADDITIONAL INSURED 3
IMPORTANT: Please note that it is not a requirement to have all the information for Additional Insured prior to quoting/binding. Once coverage is bound we can add Additional Insured to the policy upon written request to our office. Please note that there are certain entities we cannot add to the policy; if you have a specific question about acceptable Additional Insured, please contact our office.
FULL SCHEDULE / DESCRIPTION AND PURPOSE OF EVENT
*
IS THIS PART OF A LARGER FUNCTION?
IF YES, PLEASE DESCRIBE
IS THERE AN ADMISSION CHARGE?
IF YES, PLEASE DESCRIBE
DATES OF EVENT
EVENT BEGINS
Hour
Minute
Second
AM
PM
EVENT ENDS
Hour
Minute
Second
AM
PM
NAME OF LOCATION
STREET ADDRESS
CITY
STATE
ZIP
LOCATION IS
OTHER
DOES FACILITY REQUIRE A CONTRACT FOR USAGE?
*If Yes, a copy of the contract may be required.
ESTIMATED TOTAL ATTENDANCE
*
AVERAGE AGE OF ATTENDEE
MAXIMUM CAPACITY OF FACILITY
IF YOU ARE SEEKING TO HOLD MULTIPLE EVENTS FOR THE YEAR PLEASE INCLUDE A DESCRIPTION OF THE ACTIVITY, LOCATION, DATES, ATTENDANCE AND GROSS RECEIPTS BELOW
HAS THIS EVENT BEEN HELD BEFORE?
*
NUMBER OF YEARS EVENT HAS BEEN PREVIOUSLY HELD
ACTUAL TOTAL ATTENDANCE FOR PREVIOUS YEAR'S EVENT
HAVE YOU EVER HAD AN INSURANCE CLAIM AT AN EVENT SIMILAR TO THIS?
IF YES, PLEASE EXPLAIN
HAS ANY CARRIER EVER CANCELLED OR REFUSED TO RENEW SIMILAR INSURANCE COVERAGE?
IF YES, PLEASE EXPLAIN
Will the event feature rides or mechanical devices?
*
Will the event feature inflatables or other rebounding devices?
*
IF YES, HOW MANY?
Will the event feature any slides?
*
IF YES, WHAT HEIGHT?
Will the event feature animal rides or a petting zoo?
*
Will the event feature fireworks or pyrotechnics?
*
Are any of the above featured items owned by you, or your responsibility?
*
Are any of the above features items brought by an independent contractor?
*
Are these independent contractors required to name your organization as an additional insured on their insurance policy?
*
Are Vendors, Attraction Owners and Performers required to carry their own insurance?
SECURITY IS PROVIDED BY
If independent contractors, do they name your organization as an Additional Insured on their policy?
If security is the responsibility of the applicant, in what capacity?
Emergency evacuation plan in place?
Qualified medical personnel in attendance?
Ambulance service in attendance?
Is this a musical event?
PERFORMANCE DETAILS
PLEASE PROVIDE PERFORMER NAME, GENRE, LOCAL OR NATIONAL ACTS
Is this a parade event?
*
Number of floats
*
Number of marching units
*
Estimated number of spectators
Are all floats and marching units required to name your organization as an additional insured?
Liquor liability
*
Is Applicant responsible for the sale of alcohol?
If Yes, please list the estimated total liquor receipts expected from the sale of alcohol for the event
If No, is the venue or third party concessionaire responsible for the sale of alcohol?
Estimated total food sales for the event
Estimated number of attendees consuming alcohol daily
Will alcohol be dispensed by a TIPS certified professional bartender?
If No, please describe how and by whom alcohol will be dispensed
What measures are in place to prevent service of alcohol to minor and/or intoxicated persons?
Does Applicant have a valid liquor license?
Number of bars or areas at which alcohol will be dispensed at the event
Is alcohol consumption confined to this (these) areas?
Will there be an open bar?
Will alcohol be sold by the drink?
Will there be BYOB?
Cost per drink
FRAUD STATEMENT
*
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 conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
WARRANTY STATEMENT
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 on 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.
TITLE
NAME OF APPLICANT
*
SIGNATURE OF APPLICANT
*
Date
*
MM
DD
YYYY
NAME OF AUTHORIZED AGENT OR BROKER
NAME OF AGENCYAGENCY
AGENCY MAILING ADDRESS
EMAIL
PHONE
FAX
