*Required
 
Company Information
 
Company Name  
First Name*  
Last Name*  
Address*(No P.O. Boxes)  
City*  
State*  
Zip*  
Daytime Telephone Number*  
Mobile Telephone Number  
Fax Number  

Your Email Address*

 
Your Website Address (If none, supply us with a flyer of your event)  
Years Experience*  
Are you a Non-Profit Organization?*  

If yes, list all of your professional association affiliations

 
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 Policy*(Promoter, Artist, Venue, Production, Special Event, etc.)

 
Event Date(s)*  
Total Number of Shows / Performances*  
What time does event start*  
What time does event end*  
Would all attendees have left the venue by midnight of your last event date*  
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 (If there are any live performances, list all artists along with the type of music performed.)*  
Location Capacity*  
Estimated Daily Attendance (Spectators) *  
Estimated Total Attendance (All days)*  
If this event has been held before, what was the actual total attendance  
If There are Any Live Performances, or Athletes, Do You Want Participants Covered*  
Estimated Number of Unpaid Performers or Participants  

Note: Paid performers or participants must be covered under Workers' Compensation. Please also complete the Workers' Compensation section below so we can quote you.

   
Describe Participants (Example: Band Members, Theater Cast, Soccer Participants, etc.)  
List the names of all performing bands, groups, artists, celebrities, etc.*  
Admission Charge for this event*  
Number of Non-Food Vendors/Exhibitors*  
Number of Food Vendors*  
Will food vendors (if any) have their own insurance?*  
Number of Attractions (games, etc.)*  
Budget/Cost for this event*  
Estimated Gross Receipts    
Venue/Site Information
 
Name of Venue/Location*  
Will your event take place at more than 1 location? (If yes, please include a schedule in the Notes section below)  
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)  
What Per Occurrence Liability Limit does the venue require? (Found in your rental agreement)*  
What Aggregate Liability Limit does the venue require? (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*  
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 you responsible for parking?*  
Is parking lot attended?  

Will event include any Stunts, Pyrotechnics, Aircraft, Pools, Lakes or other bodies of water, Car Races, Rides, Moon Bounces, Inflatable Activities, 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 attendance per event  
Total annual attendance for all events  
Tell us about your next 5 events:    
Event Name

Type of Event

Event Dates
Attendance
     
 
 
 
 
 

Liquor Liability Option

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

 

Are you directly selling, or sharing income from the sale of alcohol?

 

If yes, what name is the liquor license filed under?

 
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. You also have the option to insure against physical damage to the rented/hired 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?  
If physical damage to rented vehicles is desired, what is the maximum value of any one vehicle?  
What is the total value of all vehicles?  
Property (Equipment & Contents) Option
 
Description of Equipment  
Describe protection, security at principal location  
Value of Owned Equipment  

Value of Rented Equipment

 
Date rented equipment is being picked up / delivered  
Date rented equipment is being returned  
Value of Office Contents  
Total Values  
Describe any prior losses/claims  

Workers' Compensation Option

Usually required by state law for employers who have 1 or more employees. Premium is based on payroll for the period of time the policy is in force. Owners / officers are excluded from coverage.

 
Payroll Company  

Payroll by job duties

# Full Time
# Part Time
Total Payroll
 
In Office Only (Clerical)  
Outside Salespersons  
Performers/Musicians  
Production Crew  
Motion Picture Production (film/video crew)  
Full names and titles of all owners or officers. Coverage will be excluded for these persons.  
Employers' Federal I.D. Number  

Staff, Volunteers, Performers & Spectator Accident Medical Option

For a quote on "no fault" medical reimbursement ("goodwill insurance"), choose this option. You are able to cover employees under this policy but it is not a substitute for workers' compensation coverage.

 
Total Number of Volunteers Daily  
Describe in detail what the volunteers will be doing. What are their duties?  
Total Number of Staff Daily  
Total Number of Performers Daily  
Do you want Spectators included in the coverage?  

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 artist, 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 performance 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 crowds to your event. Increase ticket sales. Generate publicity. Offer additional reasons for people to attend. Half-Court Shots, Picking the winning envelope, scratch off tickets, putting contests, Hole-in-One Contests. 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 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*  
Any Additional Information We Need To Know?  
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