Enter Client and Contact Information.

Client Details • Indicates required field

Primary Client Contact

Name of Company/Organization •
First Name •
Address • (No PO Boxes)
 Last Name •
City •
Phone •
State •
Email •
Zip •
 
Entity Type •  
Answer the questions to determine if this risk qualifies for the Special Event Coverage program.
Underwriting Questions
1) Does the event include any of the following? Stunts, Pyrotechnics, Aircrafts, Hazardous Activities, Car Races, Precision Driving, Mechanical Amusement Devices, Film Production, Live Rap/Hip-Hop Yes No
2) The event will take place in the United States Yes No
3) Confirm only one event can be covered per policy. Yes No
4) Any armed private security guards? Yes No

5) Any bounce houses or inflatable's? (If yes, certificates of insurance are required)

 Yes No
Enter the required information.
Event Type •
Event Name •
Cost/Budget •
Event Description •
Artist/Band Required if live music or a concert event.
Attendance • Average Daily Spectators
• Dates of Event including set-up and/or tear down days: to
• Hours of Event: - Number of Actual Event Days:
Are overnight accommodations or camping facilities provided, or contracted for, by the event organizer?
No Yes, please provide a copy of the contract.
Venue Details (Location where event takes place)
Venue Name •
Address • City •
State • Zip •   Venue Indoor? •  
General Liability
Each Occurrence
What is covered?
Covers the insured for losses due to bodily injury or property damage caused by the insured¹s employees or agents. Locations and vendors will require general liability for 1,000,000
Liquor Liability (Occurrence Aggregate)
What is covered?
Liquor liability provides covers the following losses for which you may be held liable for: 1) causing or contributing to the intoxication of a person, 2) The accidental furnishing of alcoholic beverages to a person under the legal drinking age or under the influence of alcohol, or 3) Any statute, ordinance, or regulation relating to the sale, gift, distribution, or use of alcoholic beverages. Note that host liquor is not included without purchasing liquor liability coverage.
Quotation Required
Estimated Number of Attendees consuming alcohol daily:

a. Is the Applicant the only vendor of alcohol at this event?

If NO, list names of other vendor(s):

b. Are all the participating alcohol vendors required to carry minimum Liquor Liability Limits fo rthe Event?
If YES, what is the minimum requirement?

a. Will alcohol be dispensed by a Professional Bartender?

If NO, describe how and by whom alcohol will be dispensed:


b. Describe training and/or experience of persons serving alcohol:


c. What Measures are in place to prevent the service of alcohol to minor and/or intoxicated persons?

a. Is a Liquor License required for this event?

b. Does the Applicant have a Liquor License?

a. Number of bars or areas at which alcohol will be dispensed at the Event:

b. Is alcohol consumption confined to these areas?

c. Will there be an open bar?

d. Will alcohol be sold by the drink? Cost per drink:

e. Is BYOB (Bring your own bottle) allowed?

Estimated alcohol gross receips per day:
Property
Rented Equipment, Props, Sets & Wardrobes
What is covered?
Camera, sound, lighting and miscellaneous rented equipment. Owned equipment is not covered. Props, sets, and wardrobe are covered.
How much should I insure for?
The insurable value should be the total value of your rented equipment, props, sets, and wardrobe from all vendors. Owned equipment, props, sets, and wardrobe can not be covered.
Can the deductible be changed?
No. The deductible is based on the total limit of equipment, props, sets, and wardrobe.
Are "Loss Payees" included?
Equipment insurance includes your vendors being provided with certificates of insurance naming them as loss payee in the event of a loss. Unlimited certificates can be issued.
Third Party Property Damage
What is covered?
Covers damage to property of others while in the care, custody and control of the insured (i.e. damage to the floors in a facility you are renting).
Automobile
Hired/Non-Owned Liability
Hired/Non-Owned Auto Physical Damage (Occ/Agg) 25k / 100k
What is covered?
Liability for vehicles rented for the event. Liability covers injury to third parties or damage to their property.
Additional Insureds
Do you know the Additional Insureds? •
Eligible Additional Insureds: Owners and/or Lessors of Premises, Sponsors or Co-Promoters. List the name and mailing address of any entity requiring a Certificate of Insurance evidencing them as an additional insured, and indicate their relationship to you. Please verify additional insured, and their relationship to you. Please verify additional insured language as specified in the contact wording prior to submitting enrollment form for approval. Providing a copy of the insurance section of your contract will help us complete Certificates of Insurance quickly and accurately.
1. Name • Address •
City • State • Zip •
Fax Email
Relationship • Artist Owner/Lessor of premises Sponsor Co-promoter City or Govt Entity
2. Name • Address •
City • State • Zip •
Fax Email
Relationship • Artist Owner/Lessor of premises Sponsor Co-promoter City or Govt Entity
FRAUD STATEMENT: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON, FILES AN APPLICATION FOR INSURANCE COMPANY 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 BE SUBJECT TO CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. WARRANTY STATEMENT: I HEARBY 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 CMPANY UNTIL ACCEPTED BY THE COMPANY OR THE COMPANIES IN WRITING.
• Name of Applicant Title Date

PLEASE NOTE THAT ONCE COVERAGE IS BOUND AND THE CERTIFICATES HAVE BEEN ISSUED, THE POLICY CANNOT BE CANCELED.