Home Office:
One Nationwide Plaza • Columbus, Ohio 43215
Administrative Office:
8877 North Gainey Center Drive • Scottsdale, Arizona 85258
1-800-423-7675 • Fax (480) 483-6752
EVENT/PARTY PLANNERS & COORDINATORS SUPPLEMENTAL APPLICATION
(Complete in addition to ACORD Application)
1. Name of Applicant:
2. Location of Premises:
Does Applicant own or lease (long term) a hall/banquet facility? ................................................................ Yes No
If yes, what is the square footage?
3. Types of Events (Show percentage of annual receipts by type of Event):
Event
Percentage
Event
Percentage
Auto Shows
Open Houses
Animal ShowsCat, Dog, Horse, etc.
Political Gatherings, Conventions,
Rallies*
Athletic Events/Exhibitions/Contests*
Proms
Antiques & Collectibles Shows
Includes Books, Coins, Comic Books,
Stamps & Trading Cards
Meetings/SeminarsType:
(Under 150 People in attendance)
Corporate/Business
Private
Public
Auctions*
Recitals
Baby or Wedding Showers
PartiesType:
Anniversary
Birthday
Dinner
Holiday
Office
Sporting EventTV
(i.e., Super Bowl)
Theme
Other (Describe)
Bar/Bat Mitzvahs, Baptisms, Quincenera
Barbecues
Beauty Pageants
Boat Shows
Charity EventsBanquets, Socials, Dances
Cocktail Receptions
Church Gatherings
Computer and/or Electronic Fairs/Shows
Conventions/Trade Shows*Type:
(150 or more people in attendance)
Corporate
Trade
Industry
PicnicsType:
Corporate
Employee Only
CorporateOther
Private
GLS-APP-63s (11-06) Page 1 of 4
Submit Application
Events (continued)
Event
Percentage
Event
Percentage
ExhibitionsInside*
Reunions
ExhibitionsOutside*
Rodeos/Bull Fights*
Fashion Shows
RV Shows
Festivals*
Speaking Engagements
Gun Shows
Talent Shows/Contests
Health, Science Fairs
Theatrical/Movie Premiers
Home and/or Garden Shows
Weddings & Wedding Receptions
* Provide separate detailed narrative description of Events
Musical Events*
Event Music Type* Percentage Event Music Type* Percentage
Alternative
Heavy Metal
Bluegrass
Hip Hop
Classical and/or Chamber Music
Jazz
Country/Western
Rap
Gospel & Religious
R & B
Gothic
OtherDescribe Type:
Hard Rock
* Provide separate detailed narrative description of Events
4. Number of Event dates planned for current year:
Number of Event dates held last year:
Average attendance per Event date:
Maximum daily attendance per Event:
Average length of Event (number of days):
5. Total Annual Receipts/Sales: $
Total Annual Cost of Subcontractors: $
Total Annual Payroll: $
Total Number of Employees:
6. Does the Applicant sponsor or promote any Events? ................................................................................. Yes No
If yes, provide details:
7. Is Applicant involved in any other operations or business?......................................................................... Yes No
If yes, describe:
GLS-APP-63s (11-06) Page 2 of 4
8. Services Provided (Indicate: Yes, No or N/A)
Additional Services
Performed by
Applicant &
Employees
Provided by
Subcontractors
Hired by Applicant
This Service not
Provided
Automotive ToursBus/Jeep/Other
Booking Agent
CateringFood & Non-Alcoholic Drink Only
CateringFood & Liquor
CateringLiquor OnlyBartender Service
Consulting OnlyNo other services provided
ConstructionSetup and/or Take Down
Babysitting
Fireworks
Horseback Riding
Hot Air Balloon Rides
Maintenance/Janitorial Responsibilities
Rope Courses
Security OperationsType:
Bodyguard/Personal Security
Bouncers/Crowd Control
Doormen
Parking/Traffic Control
Watchmen/Guard Service
Shuttle/Taxi/Limousine Service
Team Building ExercisesIndoor or Outside
Vehicle Valet Service
9. If work is subcontracted:
Are certificates of insurance required from all subcontractors and vendors? ............................................. Yes No
Is Applicant added as additional insured on subcontractors’ policy? .......................................................... Yes No
Are Limits of Liability on subcontractors’ policy equal to or greater than Applicant's? ................................ Yes No
Does Applicant ever use uninsured contractors or subcontractors to provide products or services for
any Event? ...................................................................................................................................................
Yes No
10. Hold-Harmless Agreements:
Does the Applicant use a standard client contract, which outlines the specific responsibilities of the
Applicant? ....................................................................................................................................................
Yes No
Do others hold Applicant harmless? ............................................................................................................ Yes No
Does Applicant agree to hold any third party harmless? ............................................................................. Yes No
Does Applicant assume, by contract or verbally, responsibility for any injury or damage that may
occur during an Event? ............................................................................................................................... Yes No
GLS-APP-63s (11-06) Page 3 of 4
11. EquipmentDoes the Applicant rent, furnish or install any of the following equipment?
Amusement Devices Barricades Bleachers Dance Floors
Folding Chairs/Tables Sound Equipment Stages/Staging Tents
Portable Restrooms Space Heaters
12. Does Applicant have Workers’ Compensation coverage in force? ............................................................. Yes No
Does Applicant lease employees? .............................................................................................................. Yes No
13. Does Applicant have Professional Liability coverage in force? .................................................................. Yes No
14. Does Applicant have Liquor Liability coverage? ......................................................................................... Yes No
15. Does the Applicant have a Web site? ......................................................................................................... Yes No
If yes, provide Web site address:
16. Attach:
(a) Any descriptive advertising literature;
(b) Copy of Applicant's standard contract with clients;
(c) Copies of all agreements in which the Applicant has assumed liability; and
(d) Separate detailed narrative descriptions as required.
Contact Person:
Phone Number:
FRAUD WARNING:
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 commits a fraudulent insurance act, which is a crime and subjects such
person to criminal and civil penalties.
FRAUD WARNING (APPLICABLE IN TENNESSEE 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 include imprisonment, fines, and denial of insurance benefits.
FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK:
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, commits a fraudulent insurance act, which is a crime, and shall also be
subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an owner, partner or executive officer)
PRODUCER’S SIGNATURE: DATE:
GLS-APP-63s (11-06) Page 4 of 4
click to sign
signature
click to edit
click to sign
signature
click to edit