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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