Fillable Form of Business Individual Partnership Corporation Association Non (Risk Placement Services, Inc.)

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Form of Business Individual Partnership Corporation Association Non (Risk Placement Services, Inc.)

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Special Event Liability Insurance Application
Special Event Liability Insurance Application
Please complete the following application. As special events vary, some questions may not be applicable. Please indicate “N/A”
where necessary. Submission of this application does not guarantee coverage.
SUBMISSION REQUIREMENTS – Please attach the following:
□ Premium and Loss Experience for the past 5 years □ Brochures of the Event
□ Copies of all Lease and Hold Harmless Agreements □ Diagram of Location(s) to be used
Name of Applicant
Mailing Address
Phone Fax
Form of Business Individual□ Partnership□ Corporation□ Association□ Non Profit□ Other□
Dates of Event Times(s)
Name of Event
Location of Event
Name of Facility
Does the Facility Carry Liability Insurance? Yes□ No□ Limits
Description of Event
How is the Event being Advertised?
Is this event Located Indoors or Outdoors?
If Outdoors, Is the Area Fenced or Enclosed? Yes□ No□
Are you Responsible for Parking? Yes□ No□ If Yes, Square Footage of Parking Area
What is the Seating Capacity of the Event? What is the Price of Admission?
What is the Estimated Attendance Per Day? What is the Estimated Gross Receipts?
How Many Athletic Participants Per Day? What is the Estimated Total Payroll?
What is the number of Tickets Printed?
What is the Number of Tickets Sold to Date?
What are the Limits of Liability Requested? $1,000,000 Each Occurrence / $1,000,000 General Aggregate□
$1,000,000 Each Occurrence / $2,000,000 General Aggregate□
$2,000,000 Each Occurrence / $2,000,000 General Aggregate□
$2,000,000 Each Occurrence / $4,000,000 General Aggregate□
Name, Address and Relationship of all Additional Insureds to be Added to the Policy:
APP-010 (0912) Page 1 of 5
Will there be any Exhibitions, Demonstrations, Parades or Pageants? Yes□ No□
If yes, Please Describe
Are Seats of Temporary or Permanent Construction?
Is Seating Reserved or General Admission?
Describe Type of Seating Provided (Bleachers, Folding Chairs, etc.)
If the Event is Outdoors, Does the Event End 90 Minutes Prior to Sundown? Yes□ No□
If No, Is there Permanent Lighting over all Spectator Areas and Parking Lots? Yes□ No□
Is any Temporary Lighting Involved? Yes□ No□
If Yes, Who is Responsible for the Hook Up of Lighting?
If Other than the Applicant, is a Certificate of Insurance Provided? Yes□ No□
If Other than the Applicant, is Applicant Named as an Additional Insured? Yes□ No□
If a stage is Involved, is the stage of Temporary or Permanent Construction?
If temporary, Who is Responsible for Set up of Stage?
If Other than the Applicant, is a Certificate of Insurance Provided? Yes□ No□
If Other than the Applicant, is Applicant Named as an Additional Insured? Yes□ No□
Is a Tent Involved? Yes□ No□
If Yes, Who is Responsible for the Set Up of the Tent?
If Other than the Applicant, is a Certificate of Insurance Provided? Yes□ No□
If Other than the Applicant, is Applicant Named as Additional Insured? Yes□ No□
What is the Number of Vendors or Trade Booths?
What goods are to be Displayed?
Are all Goods Finished Products or Demonstrations?
Are there any Cooking Demonstrations? Yes□ No□
Are Vendors or Trade Booths Required to Provide a Certificate of Insurance? Yes□ No□
Will inflatables be Present at the Event?
Who is Providing the Food and/or Drink?
If Other than the Applicant, is a Certificate of Insurance Provided? Yes□ No□
If Other than the Applicant, is Applicant Named as Additional Insured? Yes□ No□
APP-010 (0912) Page 2 of 5
Complete the following Questions if you would like a Quotation for Liquor Liability Coverage.
Estimated Number Of Attendees Consuming Alcohol Daily?
Is Applicant the Sole Vendor of Alcohol at the Event? Yes□ No□
a. If No, Please List Number of Vendors Serving Alcohol
b. Are all Participating Alcohol Vendors Required to Carry Yes□ No□
Minimum Liquor Liability Limits for this Event?
Will Alcohol be Dispensed by a Professional Bartender? Yes□ No□
a. If No, Describe How and By whom Alcohol will be Dispensed
b. Describe Training &/or Experience of Persons Serving Alcohol
What measures are in Place to Prevent Service of Alcohol to Minors and/or Intoxicated Person?
Is a Liquor License Required for this Event? Yes□ No□
a. Does Applicant have a Valid Liquor License? Yes□ No□
Number of Bars or Areas at which Alcohol will be dispensed at this Event
a. Is Alcohol Consumption Confined to this (these) Areas? Yes□ No□
b. If No, Please describe
c. Will there be an Open Bar? Yes□ No□
d. Will Alcohol be sold by the Drink? Yes□ No□
e. Cost per Drink
f. Is BYOB Permitted? Yes□ No□
Will Food be Sold or Served with the alcohol? Yes□ No□
a. If Yes, Describe Food Available
Estimated Gross Receipts per Day Alcohol Food
Total Estimated Gross Receipts from Event Alcohol Food
Has the Applicant Received any Fines or Citations in the Last 5 Years? Yes□ No□
a. If Yes, Please Describe
Has the Applicant had a Liquor Loss in the Last 5 Years? Yes□ No□
a. If Yes, Please Describe
APP-010 (0912) Page 3 of 5
Is Liquor to be sold at this event? Yes□ No□
If Yes, is there a Liquor Liability Policy In-Force? Yes□ No□
Is the Applicant Named as an Additional Insured? Yes□ No□
Are there Cooking Facilities on the Premises? Yes□ No□
If Yes, What type of Fire Protection is Present?
Is the Applicant Providing any Overnight Accommodations such as Camping? Yes□ No□
If Yes, Please Describe
Who is Responsible for Providing Security?
If Other than the Applicant, is a Certificate of Insurance Provided? Yes□ No□
If Other than the Applicant, is Applicant Named As Additional Insured? Yes□ No□
Is the Security Provided Armed or Unarmed?
If the Event is being held on a Street or Other Public Place of Vehicular Access, what Protection is being Used between the
Street and the Sidewalk?
Does the Event involve a Parade? Yes□ No□
If Yes, How many Units will there be? (each float, band or car is a unit)
Will Anything be Thrown from the Units? Yes□ No□
If Yes, What will be Thrown from the Units?
What is the Length of the Parade in Blocks? Length of Time
What is the Estimated Number of Spectators?
Are Fireworks or Pyrotechnics to be Used? Yes□ No□
If Yes, Please Describe
Is the Applicant Signing any Hold Harmless Agreements? Yes□ No□
If Yes, with Whom and What Responsibilities?
Is the Applicant being Held Harmless by Others? Yes□ No□
If Yes, by Whom and What Responsibilities?
Has this Event been held in the past by the Applicant? Yes□ No□
If Yes, for how many Years?
Please Describe any Losses over 5,000.00
Has your Prior Insurance Ever Been Cancelled? Yes□ No□
Has your Prior Insurance Ever Refused to Renew? Yes□ No□
Do you have a Risk Management Plan? Yes□ No□
APP-010 (0912) Page 4 of 5
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN
APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE
PURPOSES OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRADULENT INSURANCE ACT,
WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, DC, FL,
HI, KS, MA, MN, NE, OH, OK, OR, VT, or WA; in LA, ME, TN and VA, insurance benefits may also be denied)
IN THE DISTRICT OF COLUMBIA, WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE
PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION,
AN INSURER MAY DENY INSURANCE BENEFITS, IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE
APPLICANT.
IN FLORIDA, 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 OF THE
THIRD DEGREE.
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 ANY FACT MATERIAL
THERETO COMMITS A FRADULENT INSURANCE ACT.
IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY
INSURANCE COMPANY OR ANOTHER 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 FRADULENT INSURANCE ACT, WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON
TO CRIMINAL AND CIVIL PENALTIES.
IN WASHINGTON, IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO AN INSURANCE
COMPANY FOR THE PURPOSES OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIAL OF
INSURANCE BENEFITS.
THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE ENQUIRY HAS BEEN
MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT
AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.
Applicant’s Signature Date
Producer’s Signature Producer’s Name Date
Producer’s Telephone Number
State Producer License No National Producer Number
APP-010 (0912) Page 5 of 5
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Form of Business Individual Partnership Corporation Association Non (Risk Placement Services, Inc.)

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Completed 30 July 2020

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