Special Events Application

IF YOU ARE A VENDOR OR EXHIBITOR PLEASE DO NOT FILL THIS APPLICATION OUT
CLICK THIS LINK FOR VENDOR / EXHIBITOR COVERAGE
Client Information
Organization   Contact
Company/Organization:*   First Name:*
Entity Type:   Last Name:*
Address:(No PO Boxes)*   Phone:*
Suite, Floor, ect..:   Email:*
City*      
State Zipcode*    


Event Detail
Event Name:*
Venue Name:*
Venue Contact:*
Venue Contact Email:*
Venue Contact Phone:*
Address:*
Address Additional:
City:*
State, Zipcode*
Event Website:
Description of Event:*  
Event Dates  
Event Start Date:* MM/DD/YEAR
Event End Date:* MM/DD/YEAR
Set-up Date:* MM/DD/YEAR
Tear Down Date:* MM/DD/YEAR
If the coverage start date is more than 5 days before the event start date OR the coverage end date is more than 5 days after the event date, please explain:
Is the event outdoors?
How many years has the event been held under current management? (If never, enter 0)
During this time has the insured had any claims regarding this event?
Is there a musical performance associated with this event?
Will there be security at the insured events?
Any bounce houses or inflatable? (If yes, certificates of insurance are required)

 ALL INFLATABLE DEVICES ARE EXCLUDED ON THIS POLICY
Maximum daily attendance:*
Estimated total attendance event:*
Gross Revenue: $
Expenses: $


Coverages
General Liability
Each Occurrence
What is covered?
Covers the insured for losses due to bodily injury or property damage caused by the insured's 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.
Property  
Rented Equipment, Props, Sets & Wardrobes
Please provide a list of equipment you are renting:*
What is covered?
Camera, sound, lighting and miscellaneous rented equipment. Owned equipment is not covered. Props, sets, and wardrobe are covered.
   
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 or borrowed for the event. Liability covers injury to third parties or damage to their property.
 
Waiver of Subrogation:
The named insured's intentional relinquishing of any right to recover damages from another party who may be responsible.


Additional Insureds
Additional Insured 1
Name:   Phone:
Address:   Fax:
City:   Email:
State, Zipcode:      
Relationship: Artist - Owner - Sponsor - Government




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.