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COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

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  • 43 check-boxes
  • 18 other fields

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File type: PDF

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C‐APP037‐0815 Page1of3
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION - SPECIAL EVENT - SUPPLEMENTAL APPLICATION
ACORD Application also required - Check all applicable checkboxes below
General Agent:
Date:
Insured:
Insured Mailing Address:
Insured’s Web Address:
Insured Contact Name:
Phone Number:
PROHIBITED (check all that apply to your operations)
Attendance during any one day of the event will exceed 10,000
Air shows
Amusement rides
Animal rides
Balloon rides
Bleachers or Grandstands exceeding 4 tiers without backs
Carnivals or Circuses
Christmas Tree Lots/Farms if customers cut their own trees
Concerts or Dances – hard rock, heavy metal, rap, progressive, or any nationally known bands
Firearms Demonstrations
Fireworks
Gun shows
Haunted houses
Hayrides (unless approved by company)
Inflatables
Motor sports, Events with motorized vehicles, Motorcycle exposures
Overnight stays
Participants who are nationally known celebrities
Political Conventions, rallies or marches
Prize Indemnification coverage
Professional sports including all associated events, activities, parties & services related to the professional
sporting event.
Tractor Pulls
Water exposures including boat races & water slides
C‐APP037‐0815 Page2of3
SPECIAL EVENT - SUPPLEMENTAL APPLICATION
YEARS IN BUSINESS / EXPERIENCE
_____ Years in business as the ‘Named Insured’ indicated on this application
_____ Years’ experience in the operations indicated on this application - Attach resumes if available
Has applicant had an insurance policy cancelled or non-renewed in past 3 years? If yes, explain.
(Missouri Applicants - Do not answer this question)
Applicant in receivership
Bankruptcy (Chapter 7, 11 or 13) has been filed in past 5 years
LOSS HISTORY
Three years of loss history information provided on ACORD application or attached to this application
OPERATIONS / EXPOSURES / CONTROLS
Description of event(s):
Attendance: maximum on any one day: __________
Rodeo Events:
Events are inside of a defined arena that has protective barriers that keep spectators at least 3 feet away
Participants are not ‘pro-circuit’
Signs posted to prohibit unauthorized persons from entering activity areas
Security Provided by Applicant Includes:
Security provided by employees
Security provided by third parties – off duty peace officers
Security provided by third parties. Insured provide additional insured status to insured, and are unarmed
SUBCONTRACTORS
Uninsured subcontractors are not acceptable.
Risk Transfer – Subcontractors:
Additional Insured – Status granted to you on the subcontractor’s policy
Certificates of insurance - Always obtained from a subcontractor prior to any work being done for you.
Limits of Liability - Subcontractors are required to carry limits equal or above your own
RECEIPTS
Total receipts excluding alcohol sales
$
Total receipts from alcohol sales only
$
Liquor:
Event(s) will have alcohol being served but not being charged for
**Liquor liability requires submission of separate liquor supplemental application
COVERAGE OPTIONS - LIABILITY (check if you would like a quote on any of the following)
Employee Benefit Liability – U058
Employment Practices Liability Insurance – U817 (Not available in AR, LA, MT, NM, NY, VT)
High Limits General Liability
Identity Recovery – i.e. Identity Theft – U651
Medical Expense Limit of $10,000 rather than $5,000
Stop Gap Liability – U066
C‐APP037‐0815 Page3of3
SPECIAL EVENT - SUPPLEMENTAL APPLICATION
GENERAL FRAUD STATEMENT (Not applicable in all states.)
Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, may be committing a fraudulent insurance act, and may be subject to
a civil penalty or fine.
The undersigned is an authorized representative of the applicant and certifies that reasonable inquiry has been made to
questions on this application. He/She certifies:
The answers are true, correct and complete to the best of his/her knowledge.
They agree to the Privacy and Fraud provisions found in the ACORD-125 (Commercial Insurance Application)
and understand those provisions also apply to this supplemental application.
SIGN AND DATE
PRODUCER’S SIGNATURE DATE
APPLICANT’S PRINTED NAME DATE
APPLICANT’S SIGNATURE DATE
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COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

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Completed 17 July 2021

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