Music, Artist, & Group Supplemental

IF YOU ARE A VENDOR OR EXHIBITOR PLEASE DO NOT FILL THIS APPLICATION OUT
CLICK THIS LINK FOR VENDOR / EXHIBITOR COVERAGE
Applicant Information
Applicant Name:
Address of Applicant:
City:
State, Zip:
   
Phone:
Fax:
Email:
Inception Year:
Tax ID:


Contact Information
Business Manager
Contact Name:
Phone:
Fax:
Email:
Accountant
Contact Name:
Phone:
Fax:
Email:
Gross Payroll for Band/Crew:


Artists/Group Information
Member(s) Individual Names(s):
Member 1:
Member 2:
Member 3:
Member 4:
 
Member 5:
Member 6:
Member 7:
Member 8:
Group Details:
Music/Act Type:
Concert Length: (hours)
Total no. of shows last year:
Total no. of shows anticipated for current year:
Largest Venue in which the group preforms:
Average Capacity:
If tour is planned, overall tour dates:
No. of US dates:
No. of Canadian dates:
No. of Foreign dates:
Describe any special or unusual effects (incl. pyrotechnics), rigging and/or staging planned, or any animals to be used

Will any stunts be preformed:
Will any materials be thrown into the audience from the stage:
Does the band engage in any promoting activities:
Is the insured responsible for any concessions:
What contracts have the insured signed or will be signed requireing that the Named Insured assumes liability for the other party such as bus, trucking, venue, or equipment:
Do drivers become employees of the Named Insured:
Cost of hire (Rental Vehicles):
Describe procedure for obtaining certificates from promoters showing the band listed as additional insured:


Coverage Information
From: (Policy start date) To: (Policy termination date)

Coverage Requested Amount
Liability
H & N/O Auto:
Workers Compensation
Excess
Equipment/Gear


Prior Coverage Information (3 Year History)
Coverage Year Prior Carrier Prior Premiums
Liability Please enter your liability coverage history for the past 3 years.
 
 
 
       
H & N/O Auto Please enter your H&N/O Auto coverage history for the past 3 years.
 
 
 
       
Excess Please enter your Excess coverage history for the past 3 years.
 
 
 


Applicant
How did you hear about CSI Insurance?
Preferred contact method
 Email - Phone - Fax
Applicant Signature:*
Applicant Title:*

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.