Special Event Insurance Quote Request

Special Event Insurance Quote Request
Company Name
Full Name

First NameLast Name
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail
Years Experience
Are you a Non-Profit Organization?

General Information
Is Event Indors or Ourdoors?
Name of the Event
Type of Policy
Describe "Other"
Event dates
Total No. of Shows/Performances
Time Event

:HourMinutesAM/PM Option
until
until :HourMinutesAM/PM Option
Would all attendees have left the venue by midnightof your last event date?
Desired Effective Date (Load-in-Date)

MonthDayYear
Load-out Date

MonthDayYear
Desired Expiration Date (Usually 1 day after load-out date)

MonthDayYear
Detailed Description of the Event (If there any live performances, list all artists along with type of music)
Upload any flyers or promotional material (if available)

Upload a File

Cancelof
Location Capacity
Estimated Daily Attendance (spectators)
Estimated Total Attendance (All days)
If There are Any Performances, or Athletes, Do you Want Participants Covered?
Estimated Number of UNPAID Performers or Participants
Decribe Participants (Example: Band Members, Theater Cast, Soccer Payers, etc,)
List Names of All Performing Bands, Groups, Artists, Celebrities, Etc.
Admission Charge for the Event
Number of Non-Food Vendors
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 Information
Name of Venue/Location
Venue Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Will the event take place at more than one location?
If more than one location please include schedule
What limits of liability does the venue require? (Found on your rental agreement)
Who is supplying the security?
Is security armed?
Type of Security (Uniform, Peer Group, Ushers, Etc.)
How many of each?
Type of Seating (folding, bleanchers. etc.)
Seating is

Underwriting Information
List anyone else (other than venue) that need to be listed as additional insured on your policy, include name and complete mailing address.
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 Bouncers, Inflatable Activities or other Hazardous Activities?
If Yes Explain:
Who is responsible for setting up the stage and temporary seating?
Who was your previous insurance company?
Any previous claims (last 5 years)?
Explain any previous claims
Would you like an annual quote insuring all of the events you have planned for the next 12 months?

Optional / Additional Coverage

(complete only if coverage is requested)
- Are you directly selling, or sharing income from the sale of alcohol?
- 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 minor or intoxicated persons
- Average age of Attendees
- Average cost of drinks
- Number of patrons you will serve
- No. of vehicles rented or borrowed?
- No. of vehicles used by employees?
- Total cost to rent vehicles?
- Any vehicle 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?
- Description of equipment
- Describe protection, security at principal location
- Value of owned equipment
- Value of rented equipment
- Date equipment is being picked up / delivered
  
  MonthDayYear
- Date rented equipment is being returned
  
  MonthDayYear
- Value of office contents
- Total values
- Any prior claims?
- Describe prior claims
- Name of payroll company (is any)
- Employers' Federal ID Number
- List No. of Full Time / Part Time employees and Payroll per duties/class code
- List full names and titles of all owners and officers. Coverage will be excluded for these persons
- Number of staff
- Number of volunteers
- Do you want spectators to be included on coverage?
- Coverage date
  
  MonthDayYear
- Coverage time
  
  :HourMinutesAM/PM Option
  until
  until :HourMinutesAM/PM Option
- Policy limit
- Include the following perils (check all that apply)
- List any additional dates and times for coverage
- Is the event indoors?
- Is the performance under a cover?
- Would bad weather cause cancellation of your event?
- Budgeted total gross revenue
- Budgeted total expenses
- Net income (revenue less expenses)
- Describe to us the type of prize promotion you want including the value of the prize

Application Warranty and Signature
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
Title
Date of acknowledgment

MonthDayYear
Should be Empty: