Fillable Application - Event Planner36-11273

Fill Online, Printable, Fillable, Blank Application - Event Planner36-11273 Form

Use Fill to complete blank online PHILADELPHIA INSURANCE COMPANIES pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Application - Event Planner36-11273

On average this form takes 18 minutes to complete

The Application - Event Planner36-11273 form is 3 pages long and contains:

  • 0 signatures
  • 4 check-boxes
  • 71 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Philadelphia Insurance Companies forms online.

BROWSE PHILADELPHIA INSURANCE COMPANIES FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
EVENT PLANNER APPLICATION
ELIGIBLE RISKS
Event planners assist their clients with finding the best venues and vendors for the clients’ events – whether the event is a
wedding, party, business meeting etc. For the purposes of this program, event promoters or event planners providing the
following are not eligible.
• Event promoters – insured is the host or sponsor of the event.
• Event planner who signs contracts with venues or vendors on behalf of their clients
• Event planners who provide staffing services (bartenders, wait service, valets, etc.)
• Event planners who promote, sponsor or hire entertainment including performers or DJ’s.
• Event planners who own / operate the event venue.
SUBMISSION REQUIREMENTS
• Copy of contract between prospect and client.
• Currently valued insurance company loss runs for the current policy period plus three (3) prior years
GENERAL INFORMATION – to be completed by all Applicants
1. Name of Applicant (as it should appear on the policy):
(legal name of the business or organization; typically the name that would appear on any contracts or agreements)
2. Mailing Address:
3. City: State: Zip:
4. Contact Person: Telephone:
Cell: Fax:
5. Website Address: E-Mail:
6. Office Location if different from mailing address:
7. Risk Management Contact: Risk Management’s Phone:
Risk Management Email:
SECTION I - OPERATIONS
1. Describe the Applicant’s typical events and services offered:
2. Number of years in business:
3. Annual Receipts: Annual Payroll # of Employees:
4. Are sub-contractors used? Yes No
a. If yes, please describe the sub-contracted services provided:
b. Total cost of sub-contractors: $
c. Does the Applicant require to be listed as an additional insured? Yes No
d. Does the Applicant obtain a certificate of insurance for their records? Yes No
NOTE: Independent contractors (non-employees) are not covered by this program. The Applicant
should obtain a certificate of insurance from any sub-contractor naming Applicant as an additional
insured.
Event Planner Application
Page 1 of 3
© 2015 Philadelphia Consolidated Holding Corp.
09/2015
Print Application
Clear Application
5.
Does the Applicant install sets, lighting, or stages?
Yes
If yes, please describe:
6.
Does the Applicant sign any contracts on behalf of the client?
Yes
7.
Will the Applicant allocate expenses or manage a financial account on behalf of Applicant’s client?
Yes
8.
Is the Applicant involved in any other business operations?
Yes
If yes, please explain:
SECTION II – HIRED AND NON-OWNED AUTO
1.
Does the Applicant have any owned automobiles?
Yes
NOTE: If the Applicant has owned autos, the hired car and non-owned auto coverage should be
placed with the automobile carrier. Explain if an exception is requested:
2. Does the Applicant allow employees to use their own personal vehicles for your business
purposes?
Yes
If yes, how many employees use their own personal vehicles:
If yes, how often:
Daily
Weekly
Monthly
Other:
3.
Does the Applicant obtain Motor Vehicle Reports?
Yes
If yes, how often:
Annually
Every other year
Other:
4. Does the Applicant confirm that all employees who regularly use their cars for business purposes
carry minimum personal auto limits?
Yes
If yes, what minimum limits are required: $
5.
Please provide the approximate cost of hire for all hired or leased autos during the course of a
policy period? $
6.
Is hired auto physical damage required?
Yes
If yes, what is the maximum value of hired vehicle the Applicant would like insured? $
NOTE: Hired Car Physical Damage deductibles: $100 Comprehensive/$1,000 Collision provided.
Event Planner Application
Page 2 of 3
© 2015 Philadelphia Consolidated Holding Corp.
09/2015
Clear Application
Print Application
FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief
and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true
and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes
prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the
quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE 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 SUBJECTS THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE
IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO
KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE
OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM
INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY
AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER
FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A
FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED OR
PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR ANY AGENT
THEREOF, ANY WRITTEN STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN
INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN
INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION
CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT
MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT,
FINES OR A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATOIN FOR INSURANCE 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 A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR
EXECUTIVE DIRECTOR)
____________________________________________________
SIGNATURE DATE
SECTION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
Event Planner Application
Page 3 of 3
© 2015 Philadelphia Consolidated Holding Corp.
09/2015
Clear Application
Print Application
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Application - Event Planner36-11273

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 2 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document