Fillable Mtspt Event App Package

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Mtspt Event App Package

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Key Underwriting/Qualifying
Factors (Including but not limited to):
- Must meet K&K motorsport insurability
guidelines
Ineligible for this program:
- Noncompetitive participation facilities
(i.e., go kart concession tracks, off-road
vehicle parks, mud parks)
- Drag boat racing
K&K Benefits:
- Experienced & professional staff dedicated
exclusively to servicing the K&K Motorsports
Programs for over 65 years
- Attendance at industry conventions
including RPM Promoters Workshops,
Performance Racing Industry Trade Show
(PRI)
- Active industry involvement through
sanctioning bodies, racing associations and
event attendance
- In-house underwriting, policy administration,
loss control and claims services
- 24-hour emergency claims phone service
- Insurance carriers rated “A” or higher by
A.M. Best
- Interest-free premium installment plans
available
MOTORSPORTS
Facilities & Events
Insuring the world’s fun®
No other organization has the knowledge and experience that
allows K&K to provide superior coverage for world-renowned
racing organizations as well as local tracks, teams and drivers.
K&K Insurance has provided motorsports insurance to the
industry since 1952 and is still the leader in the industry today.
A wide range of products are available to protect motorsports
facilities and/or event promoters. From liability and participant
accident coverages to property and commercial auto coverages,
K&K has it covered.Programs are available to cover facility
operators,specialtyeventpromotersandsanctioning
organizations.
Coverages Available & Program Highlights:
General Liability
- No General Aggregate
- Separate Limits for Legal Liability to Participants
- Expanded Bodily Injury Definition
- Personal and Advertising Injury
Definition Expanded
- Official Vehicle Physical Damage
- Motorsports Errors & Omissions
- Customized Motorsport Policy Language
- Host Liquor Liability
- Cyber Risk ($25,000 sublimit)
Participant Accident Coverage
- Accidental Death & Specific Loss
- Accident Medical Benefits Available on Excess
or Primary Basis
- Limits up to $1,000,000
- Volunteer- Accident Medical Coverage for
Motorsport Volunteers
- Weekly Accident Income
Property
Crime
Inland Marine
Commercial Auto
Liquor Liability
Excess Liability
Event Cancellation & Non-appearance
Workers Compensation
Additional Products:
- Contingency/Prize - High Limit Disability
Indemnity - Products Liability
- Employment Practices
Liability
Eligible Operations:
- Boat racing
- Demo derbies
- Drag racing
- Independent car
club activities
- Karting
- Motorcycle racing
- Motorsports
country clubs
- Motorsports driving
schools
- Short track oval
racing
- Racing associations
- Road courses
- Snowmobile
competitions
- Specialty
motorsports events
- Super speedways
- Tractor/truck pulls
Submission Instructions:
To request an insurance quotation through this program,
please submit the appropriate applications along with the
preliminary underwriting information listed. In some cases,
requested coverages may not be offered or available due to
underwriting criteria and/or carrier guidelines. It is important
to carefully review the terms and conditions of any insurance
quotations received. Please contact a K&K representative if
you have any questions.
Preliminary Underwriting Information
Required:
- K&K Application(s) (see below)
- ACORD application(s) for other requested coverages
- Five years of company loss runs
- Diagram of event locations
- Schedule of events
- Copies of contracts where insured assumes liability of others
Motorsports Facilities & Events Application(s):
(Applications can be obtained from our web site: kandkinsurance.com)
K&K Application(s)
- Motorsport Facilities Application (if needed)
- Property Insurance Questionnaire (if needed)
- Premises Liability Insurance Application (if needed)
- General Application (if needed)
- Permanent Facility Event Enrollment Form (if needed)
- Temporary Event Motorsports Enrollment Form (if needed)
- Liquor Liability (if needed)
- Fireworks Application- Motorsports (if needed)
ACORD Application(s)
- Property
- Commercial Auto
- Crime
- Inland Marine
- Excess Liability
Insuring the world’s fun®
Contact Information:
1712 Magnavox Way
P.O. Box 2338
Fort Wayne, IN 46801-2338
Motorsports Facilities & Events
Program
PHONE: 800.348.1839
FAX: 260.459.5118
EMAIL:
KK.Motorsports@kandkinsurance.com
WEB SITE:
kandkinsurance.com
K&K Insurance Group, Inc. is a licensed insurance
producer in all states (TX license #13924);
operating in CA, NY and MI as K&K Insurance
Agency (CA license #0334819)
11/18
Name of Insured (
as will appear on policy
): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Doing Business As: ______________________________________________________________________________________
Mailing Address: ________________________________________________________________________________________
City: _______________________________ State: ________ Zip: ____________ Phone: ( _____ ) ____________________
Location Address (if different from above): ____________________________________________________________________
City: _______________________________ State: ________ Zip: ____________ Phone: ( _____ ) ____________________
Contact Person: ________________________________________________________________________________________
Person is: ❏ Owner ❏ Promoter ❏ Agent ❏ Other: ______________________________________________
Day Phone: ( _____ ) _______________ Night Phone: ( _____ ) _______________ Fax: ( _____ ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
E-mail Address: ________________________________________________________________________________________
Web Site Address: ______________________________________________________________________________________
Name of Agency/Brokerage (if applicable): __________________________________________________________________
Contact Person: ________________________________________________________________________________________
Mailing Address: ________________________________________________________________________________________
City: _______________________________ State: ________ Zip: _____________ Phone: ( _____ ) ____________________
Fax: ( _____ ) ______________________ E-mail address: _________________________ Tax ID: ____________________
Nature of operations/description of event: ____________________________________________________________________
_____________________________________________________________________________________________________
Insured is: ❏ Corporation ❏ Partnership ❏ Joint Venture ❏ Other (explain):
❏ Limited Liability Corporation
In what state is the organization headquartered/chartered? ______________________________________________________
Policy period requested: From ________________________________ To ________________________________________
Estimated number of events: ______________________________________________________________________________
COVERAGE INFORMATION
Check the type of coverage and indicate the limits desired:
❏ General Liability ❏ Primary ____________________________________________________
❏ Excess ____________________________________________________
❏ Legal Liability To Participants __________________________________
❏ Participant Accident and Health ❏ AD&D ____________________________________________________
(Applicable only to Motorsports)
❏ Primary Medical ____________________________________________
❏ Excess Medical ______________________________________________
❏ Weekly Disability Income ______________________________________
❏ Property Casualty ❏ Property____________________________________________________
❏ Inland Marine ______________________________________________
❏ Auto ______________________________________________________
❏ Workers’ Compensation
❏ Other: ______________________________________________________________________________________
____________________________________________________________________________________________
1097 10/03
GENERAL
APPLICATION
Page 1 of 12
UNDERWRITING INFORMATION
1 . Has this type of insurance ever been: ❏ Cancelled ❏ Declined ❏ Non-renewed If so, please explain. (Not applicable
in Missouri).
________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
2. Does this organization engage in any other business operations under the name of the insured as it will appear on the policy?
❏ Yes ❏ No If yes, please explain. ____________________________________________________________
__________________________________________________________________________________________________
3. As respects your operation(s), do you enter into any contracts? ❏ Yes ❏ No If yes, what contracts do you enter into?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
a. Does the Named Insured assume liability for the other party? ❏ Yes ❏ No
PLEASE PROVIDE COPIES OF ALL CONTRACTS OF THIS TYPE.
b. Does the other party assume the Named Insured’s liability? ❏ Yes ❏ No
PLEASE PROVIDE ONE SAMPLE OF THIS TYPE.
c. Does each party assume its own liability? ❏ Yes ❏ No
4. Who reviews the contracts prior to signing?
❏ Corporate Officers ❏ Counsel ❏ Other (please explain) __________________________________________
5. For each of the following, please indicate if there is a procedure in effect for obtaining certificates of insurance, the limits
required for each and whether the certificates list the Named Insured as it will appear on the policy as an Additional Insured.
CERTIFICATES LIMITS ADDITIONAL INSURED
(Provide copies.)
Food Concessionaires ______________________ ______________________ ________________________
Vendors/Exhibitors ______________________ ______________________ ________________________
Contractors/Others ______________________ ______________________ ________________________
6. Is a K&K approved Waiver and Release form read and signed by all persons entering a restricted area prior to entry?
(Applicable only to Motorsports) ❏ Yes ❏ No
PRIOR CARRIER INFORMATION (NEW BUSINESS ONLY)
YEAR PREVIOUS AGENT COMPANY LIABILITY LIMITS PREMIUM LOSSES
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
PLEASE SUBMIT A COPY OF PREVIOUS/PRESENT POLICY(IES)
I understand that the insurance company in determining whether to provide a quotation for insurance coverage will rely
on the information contained in the application and all other information being submitted. I hereby warrant, represent and
confirm that, to the best of my knowledge, all information provided is complete, true and correct.
__________________________________________________ _________________________________________________
Applicant’s Signature Producer’s Signature (if applicable)
__________________________________________________ _________________________________________________
Applicant’s Name (print) Producer’s Name (print)
__________________________________________________ _________________________________________________
Date (MM/DD/YY) Date (MM/DD/YY)
1097 10/03
Page 2 of 12
1. Facility Name:
2. Type of Event:
3. Club, Association, or Promoter:
Address:
City: State: Zip:
Phone:
4. Event Dates:
Practice Dates:
Qualifying Dates:
Competition Dates:
5. Number of Vehicles: Maximum number of vehicles on track at one time:
Type of Vehicles:
Number of Participants:
Event open for public viewing? Yes No
If yes, estimated public attendance:
6.
Coverages Requested:
Liability Limits: $
Participant Accident: $
Accidental Death & Dismemberment: $
Medical: $ Primary Excess
Weekly Indemnity: $ For a period of weeks.
7. Premium Remitted:
Check No.:
8. Additional Insureds and Relationship:
9. Send Certificate to:
Name: Email:
Address:
Phone: Fax:
10. Authorized Signature:
11. Special Requests:
RETURN TO: K&K INSURANCE GROUP, INC., P.O. BOX 2338 1712 MAGNAVOX WAY, FORT WAYNE, INDIANA 46801
IF A CERTIFICATE OF INSURANCE IS NEEDED, PLEASE SUBMIT THIS APPLICATION,
ALONG WITH PREMIUM, ONE WEEK PRIOR TO THE EVENT TO INSURE PROPER MAIL TIME.
PERMANENT FACILITY
EVENT ENROLLMENT FORM
1712 Magnavox Way P.O. Box 2338
Fort Wayne, IN 46801-2338
(800) 348-1839 Fax (260) 459-5118
www.kandkinsurance.com
CA# 0334819
I understand that the insurance company in determining whether to provide a quotation for insurance coverage will rely on the information con-
tained in the application and all other information being submitted. I hereby warrant, represent and confirm that, to the best of my knowledge, all
information provided is complete, true and correct.
Applicant’s Signature Producer’s Signature (if applicable)
Applicant’s Name (print) Producer’s Name (print)
Date (MM/DD/YY) Date (MM/DD/YY)
1008 1/09
FACILITY UNDERWRITING MANDATORY TO PROVIDE COVERAGE AND CERTIFICATE OF INSURANCE.
PLEASE COMPLETE THE EVENT LOCATION DIAGRAM SHEET FOR EACH EVENT LOCATION.
Submit this completed insurance enrollment form (2) weeks prior to event.
CLUB ASSOCIATION OR PROMOTER:
ADDRESS:
Contact: Phone:
Additional Named Insureds Business Relationship
a.
b.
c.
EVENT DATE(S): Event is to be held: Indoors Outdoors
FACILITY NAME:
City: State:
Only those activities and events listed below and approved by the underwriter will be endorsed onto the policy.
TYPE OF EVENT: VEHICLE CLASS:
(Attach full schedule of events)
List all Ancillary Attractions included during event (i.e. tee shirt slingshot, bat spin, nickle pitch...):
Provide minimum ages of participant in each vehicle class.
Limits of Coverage Requested:
Do you intend to provide coverage for participants? Yes No
Send certificate to:
Name:
Address:
Special Instructions:
BARRIER:
Are there Guard Rails protecting all spectator and participant areas? Yes No Type of Material Used:
Height of Guard Rail? " If other than concrete, what are the support posts?
Distance apart?
FENCE:
Is there a Crowd Control Fence? Yes No Type of Material: Height:
Does the Crowd Control Fence restrict all viewing persons behind the Guard Rail/Wall? Yes No
If at a fairground, are all Spectators restricted to the Grandstand? Yes No
GRANDSTANDS:
Yes No Age: Construction:
Distance between course and grandstand: Seating Capacity:
Distance between grandstand and crowd control fence:
Estimated Attendance: Time Period of Show: hours.
1712 Magnavox Way
Fort Wayne, Indiana 46801
(800) 553-8368 Fax (260) 459-5624
www.kandkinsurance.com
CA# 0334819
MOTORSPORTS
TEMPORARY EVENT
ENROLLMENT FORM
1127 (12/05)
Page 4 of 12
Any rows blocked off during event? Yes No If yes, show on diagram.
Ambulance present? Yes No Fire Extinguishers? Yes No Type:
Number of EMTs
Are you using K&K Insurance Release Form Procedures? Yes No
Number and type of security personnel: Uniformed Officers Contracted Employees
FOR MONSTER TRUCKS:
Do all trucks have remote ignition kill systems? Yes No
If Yes, are all systems tested prior to each event? Yes No
Ride truck present? Yes No If Yes, provide details regarding trucks and program.
List any specialized vehicle exhibitions (i.e. jet vehicles, freestyle motocross, etc.)
Do all monster trucks participating meet or exceed the standards outlined in the current MTRA rulebook? Yes No
FOR AUTOCROSS, RIDE AND DRIVE, DRIVING SCHOOL AND DRIFTING TYPE EVENTS:
What is the maximum speed allowed?
Maximum number of cars on course at one time?
FOR DRIVING SCHOOLS:
Number of instructors? Number of students?
List experience of all instructors
Percentage breakdown of school instruction: Classroom time %, On track time %
Passing allowed? Yes No If Yes, under what circumstances?
Who maintains school vehicles?
FOR RIDE AND DRIVE EVENTS:
Describe format of event (ie., dealer test drive, follow the leader, exhibitions with professional drivers...)
Are passengers allowed? Yes No If Yes, what is the minimum age?
Is there any public road exposure? Yes No
RETURN TO K&K INSURANCE GROUP, INC., 1712 MAGNAVOX WAY, P.O. BOX 2338, FORT WAYNE, IN 46801
PHONE 800-553-8368 • FAX 260-459-5624
IMPORTANT: COVERAGE WILL NOT BE PROVIDED UNLESS FOLLOWING PAGE IS COMPLETED FOR EACH LOCATION.
I understand that the insurance company in determining whether to provide a quotation for insurance coverage will rely on the informa-
tion contained in the application and all other information being submitted. I hereby warrant, represent and confirm that, to the best of
my knowledge, all information provided is complete, true and correct.
Applicant’s Signature Producer’s Signature (if applicable)
Applicant’s Name (print) Producer’s Name (print)
Date (MM/DD/YY) Date (MM/DD/YY)
1127 (12/05)
Page 5 of 12
S security
X fire extinguishers
A ambulance
C concessions
R rest rooms
N north
_______–_______–_______ barrier
_______________________ fence over 5'
fence under 5'
photograph
EVENT LOCATION DIAGRAM SHEET
CURRENT SURVEY REQUIRED - (CURRENT MEANS AT LEAST EVERY TWO YEARS.)
VERY IMPORTANT: POLICIES/CERTIFICATES/BINDER WILL NOT be processed by Underwriter unless a DETAILED
DIAGRAM and SUPPORTING PHOTOS accompany enrollment form and applicable premium.
SHOW LOCATION AND IDENTIFY: Spectator viewing area, spectator parking areas, restricted areas, pit areas, com-
petition course, barrier, fences, concessions, restrooms, fire extinguishers, ambulance, security personnel, distance
between course and nearest crowd control fence and direction North.
PICTURES MUST BE TAKEN: Between course and any area used by spectators and/or participants, parallel to course
and barrier/fence. (Note direction taken and number photo)
USE SYMBOLS: include the following symbols in your diagram.
Indicate photograph number in circle and position
arrow in the direction the photo was taken.
Indicate the direction of NORTH on diagram
Underwriting Surveys. K&K, for the insuring company, shall be permitted but not obligated to survey the Insured's property and operations for underwriting pur-
poses at any time. Neither the right to make an underwriting survey nor the making thereof nor any report thereon shall constitute an undertaking, on behalf of,
or for the benefit of, any Insured, or others, to forecast any accident or its severity or determine or warrant that such property or operations are safe or helpful, or
are in compliance with any engineering standards, rule or regulations. Underwriting surveys are for the sole purpose of determining the insurability of certain prop-
erty and operations and not safety. The Insured is solely responsible for the safety of its facilities and operations and shall not rely upon any underwriting surveys
to determine the safety of its track or operations and shall not diminish or forego its own safety practices and procedures.
I ATTEST THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND COMPLETE
SIGNATURE OF INSURED TITLE DATE
THIS IS NEITHER AN OFFER OF COVERAGE NOR AN APPLICATION
FOR INSURANCE. REQUESTS FOR COVERAGE WILL BE SUBJECT TO
COMPANY UNDERWRITING STANDARDS. ACTUAL COVERAGE TERMS
WILL BE DESCRIBED IN A POLICY OF INSURANCE IF ONE IS ISSUED.
Received Date Stamp
1127 (12/05)
Page 6 of 12
(To be completed and returned with Commercial Auto ACORD application)
Named Insured: ___________________________________________________________________________________
Do you have a Business Auto Policy for owned autos? ❏ Yes ❏ No
If yes, can coverage be obtained under your Business Auto Policy? ❏ Yes ❏ No
If no, please explain: _______________________________________________________________________________
NON-OWNERSHIP LIABILITY
1. Do employees or volunteers routinely use their autos for company business? ❏ Yes ❏ No
If so, please provide details regarding duties involved: _________________________________________________
2. Do you verify that insurance is in place with limits of at least
$300,000 before employees or volunteers can use their auto? ❏ Yes ❏ No
3. Do you run motor vehicle reports on each employee? ❏ Yes ❏ No
4. Please explain what other controls you have in place to protect your company’s liability? _______________________
______________________________________________________________________________________________
5. Number of Employees ________________ Number of Volunteers ________________
HIRED AUTO LIABILITY
1. During the last three years have you leased, borrowed or hired any vehicles for your business? ❏ Yes ❏ No
2. If you anticipate some usage this year:
A. What type of vehicle (trucks, cars, buses)? ________________________________________________________
B. What is the estimated cost to lease or hire the vehicles? ______________________________________________
3. When leasing, hiring or borrowing are the vehicles used to:
A. Transport participants, volunteers or staff only? ❏ Yes ❏ No
If yes, how many? ________________ For how long? _________________
Number of times per year: ______________ Distance traveled per trip: _______________
B. Haul equipment: ❏ Yes ❏ No
If yes, please explain and identify frequency and distance traveled per trip: _______________________________
___________________________________________________________________________________________
4. If using buses or vans, please answer each of the following:
Maximum number of passengers each vehicle carries: ______________ Distance traveled per trip: _____________
How long the vehicles will be used: ______________ Year built: _________________ Cost new: ______________
5. Does the leasing company provide drivers or do you use your own? ______________________________________
6. Do you purchase liability insurance from the leasing company? ❏ Yes ❏ No
7. Does the vehicle owner(s) require you to provide primary insurance and to add them as
additional insureds? ■ Yes ■ No If yes, please explain: ____________________________________________
8. What is the estimated annual cost to hire/lease all vehicles? _____________________________________________
9. Do you hire vehicles for more than or less than 30 days for any one time? ❏ More ❏ Less
If more than 30 days, vehicles should be scheduled.
NONOWNED/HIRED
AUTO QUESTIONNAIRE
1092 (12-03)
Page 7 of 12
HIRED AUTO PHYSICAL DAMAGE
1. What types of vehicles have you leased or do you intend to lease (Make/Model/Size)? ________________________
_____________________________________________________________________________________________
2. What is the highest valued vehicle you have leased or intend to lease (Type/Value)? __________________________
_____________________________________________________________________________________________
3. Do drivers share in the loss exposure (i.e. driver pays half of the deductible)? ❏ Yes ❏ No
4. What is the maximum number of vehicles leased at one time? ___________________________________________
5. Please provide the garage location of the vehicles (city and state): ________________________________________
6. Requested Comprehensive Deductible? $____________________ Collision Deductible? $ ____________________
LIST OF DRIVERS- Please provide the following information for each driver.
Name Birth Date Driver’s License Number State Licensed
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
LEASED VEHICLES
If leased, what is the term of the lease? _____________________________________________________________
VIN# Year Make Model New Cost Garaging Location (City and State)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
I understand that the insurance company in determining whether to provide a quotation for insurance coverage will rely
on the information contained in the application and all other information being submitted. I hereby warrant, represent and
confirm that, to the best of my knowledge, all information provided is complete, true and correct.
__________________________________________________ _________________________________________________
Applicant’s Signature Producer’s Signature (if applicable)
__________________________________________________ _________________________________________________
Applicant’s Name (print) Producer’s Name (print)
__________________________________________________ _________________________________________________
Date (MM/DD/YY) Date (MM/DD/YY)
1092 (12-03)
Page 8 of 12
LIQUOR LIABILITY
APPLICATION
1. Named Insured as it is to appear on policy:
Telephone Number: (
) Fax Number: ( )
2. Name Liquor License is in:
3. Liquor License Number: Class of License:
4. Is coverage for a specific event? ❏ Yes ❏ No If yes, explain what kind of event, where event will be held and date
of event(s). ___________________________________________________________________________________
5. Opening and closing hours of event(s) (for each event):
6. Opening and closing hours of alcoholic beverage sales for each event. (Must cease a minimum of 1/2 hour before event
closing).
7. Has applicants’ alcohol beverage license ever been revoked, suspended or fined? ❏ Yes ❏ No
If yes, please explain:
8. Has applicant incurred claims for liquor liability during the last three years? ❏ Yes ❏ No
If yes, please explain:
9. Has any insurer cancelled or non-renewed coverage during the last three years? ❏ Yes ❏ No
If yes, please explain:
10. Type of alcohol beverages sold:
What proof:
11. Annual Gross Sales:
Event Alcoholic Beverage Sales Food Sales
$ $
$ $
$ $
$ $
12. Are patrons allowed to carry alcoholic beverages onto the premises? ❏ Yes ❏ No
If yes, what type?
13. Do you maintain security personnel at event entry check points? ❏ Yes ❏ No
If yes, what type?
Do they exercise the right of search and seizure of contraband items? ❏ Yes ❏ No
If yes, how do they notify the public of this?
14. Are the alcohol sales and consumption contained by fencing within one fixed site or are
booths/stands located throughout the event site (at each event)? ❏ Yes ❏ No
15. If site is completely enclosed, are minors allowed
to enter?
❏ Yes ❏ No
(Continued on next page)
1057 10/03
Page 9 of 12
16. Are the servers professional (two years bartending experience or more)?
❏ Yes ❏ No
Are the servers non-professional (less than 2 years or no bartending experience)?
❏ Yes ❏ No
Explain:
17. Name the formal awareness training program that the servers receive:
18. At what point of sale are I.D.’s checked?
19. Are rules and regulations clearly displayed for patrons’ viewing?
❏ Yes ❏ No
Explain:
20. In what size container is the alcoholic beverage served at each event?
❏
Cup ______ oz.
❏
Pitcher
❏
Other:
21. Can patrons purchase more than two alcoholic beverages at one time?
❏ Yes ❏ No
If yes, please explain:
22. Is there any type of designated driver program in effect?
❏ Yes ❏ No
Explain:
23. Is there any other Liquor Liability coverage being provided?
❏ Yes ❏ No
If yes, explain and attach a copy of the certificate of insurance:
24. Liability limits requested $____________ (per occurrence) $____________ (aggregate)
I understand that the insurance company in determining whether to provide a quotation for insurance coverage will
rely on the information contained in the application and all other information being submitted. I hereby warrant,
represent and confirm that, to the best of my knowledge, all information provided is complete, true and correct.
__________________________________________________ _________________________________________________
Applicant’s Signature Producer’s Signature (if applicable)
__________________________________________________ _________________________________________________
Applicant’s Name (print) Producer’s Name (print)
__________________________________________________ _________________________________________________
Date (MM/DD/YY) Date (MM/DD/YY)
1057 10/03
1094 (05/15)
1. Name of Insured:
2. Date(s) of fireworks exposure:
3. Specific location of fireworks display(s):
4. Estimated spectator attendance:
5. Name of organization shooting fireworks:
6. Will other coverage be provided? q Yes q No
If yes, please attach copy of certificate with your name listed as additional insured (minimum limit of $1,000,000 required).
7. List names of individuals shooting fireworks and their experience (bodily injury to shooters is excluded):
Name Experience
If insured is shooting fireworks, provide copy of current license.
8. Is a permit required by State, City, County authority for this fireworks display? q Yes q No
If yes, please explain
9. Provide diagram of the fireworks display area, detailing the following information:
a. Spectator fencing – distance from launch site to spectators
b. Launch site
c. Direction of launch
d. Spectator parking lot
e. Concessions area
f. Surrounding areas
10. Describe firefighting equipment on site of event:
11. If no firefighting equipment on site, give distance to nearest fire station:
Fire protection is: q Volunteer q Paid
12. Do you have a licensed EMT-staffed ambulance on site during all fireworks displays? q Yes q No
If no, give distance in miles to nearest medical facility: and response time in minutes:
13. Have you displayed fireworks before? q Yes q No
If yes, describe any claims/losses that have occurred and the amount of loss:
14. Limit of Liability requested (cannot be greater than the event limit): o $500,000 o $1,000,000
I understand that the insurance company in determining whether to provide a quotation for insurance coverage will rely on the informa-
tion contained in the application and all other information being submitted. I hereby warrant, represent and confirm that, to the best of
my knowledge, all information provided is complete, true and correct.
Applicant’s Signature Producer’s Signature (if applicable)
Applicant’s Name (print) Producer’s Name (print)
Date (MM/DD/YY) Date (MM/DD/YY)
FIREWORKS
SUPPLEMENTAL
APPLICATION
MANDATORY SIGNATURE SUPPLEMENT TO ALL
APPLICATIONS, QUESTIONNAIRES, & ENROLLMENT FORMS
I understand that K&K Insurance Group, Inc., for the insuring company, shall be permitted but not obligated to inspect a proposed insured’s, or an
insured’s, property and operations for underwriting purposes at any time. Neither the right to make an underwriting inspection nor the making thereof
nor any report thereon shall constitute an undertaking, on behalf of or for the benefit of any insured, or other, to determine or warrant that such property
or operations are safe or healthful, or in compliance with any standards, rules or regulations. Underwriting inspections when conducted are for the sole
purpose of determining and/or improving the insurability of certain property and operations and not safety. I also understand that an insured is solely
responsible for the safety of its facilities and operations and shall not rely upon any underwriting inspections to determine the safety of its facilities or
operations and shall not diminish or forego its own safety practices and procedures.
I understand that the insurance company in determining whether to provide a quotation for insurance coverage will rely on the information contained
in the application and all other information being submitted. I hereby warrant, represent and confirm that, to the best of my knowledge, all information
provided is complete, true and correct.
I also understand that no insurance will be in effect unless and until the insurance company, or K&K as its agent, provides a quotation offering to provide
insurance coverage and the insurance company, or K&K as its agent, receives written notice that the terms and conditions contained in the insurance
quotation provided are accepted.
1030 11/19
_______________________________________________________________ __________________________________________________________________
APPLICANT’S SIGNATURE PRODUCER’S SIGNATURE (if applicable)
_______________________________________________________________ __________________________________________________________________
PRINT NAME PRINT NAME
_______________________________________________________________ __________________________________________________________________
DATE (MM/DD/YY) DATE (MM/DD/YY)
THE NOTICES CONTAINED ON THIS SUPPLEMENT APPLY TO ALL UNDERWRITING INFORMATION BEING SUBMITTED TO K&K INSURANCE
GROUP, INC., INCLUDING APPLICATIONS, QUESTIONNAIRES AND ENROLLMENT FORMS, FOR THE FOLLOWING PERSON OR ENTITY:
Applicant name:
FRAUD WARNING
Applicable in AL
Any person who knowingly presents a false or fraudulent claim for payment of
a loss or benefit or who knowingly presents false information in an application
for insurance is guilty of a crime and may be subject to restitution fines or
confinement in prison, or any combination thereof.
Applicable in AR, LA, MD, RI and WV
Any person who knowingly (or willfully)* presents a false or fraudulent claim for
payment of a loss or benefit or knowingly (or willfully)* presents false information
in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison. *Applies in MD Only.
Applicable in CO
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 DC
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.
Applicable in FL
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.
Applicable in KY
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.
Applicable in ME, TN, and WA
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 and denial of insurance benefits. *Applies in ME Only.
Applicable in NM
Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application
for insurance is guilty of a crime and may be subject to civil fines and criminal
penalties.
Applicable in NJ
Any person who includes any false or misleading information on an application for
an insurance policy is subject to criminal and civil penalties.
Applicable in NY
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.
Applicable in OH
Any person who, with intent to defraud or knowing that he is facilitating a fraud
against an insurer, submits an application or files a claim containing a false or
deceptive statement is guilty of insurance fraud.
Applicable in OK
WARNING: Any person who knowingly, and with intent to injure, defraud or
deceive any insurer, makes any claim for the proceeds of an insurance policy
containing any false, incomplete or misleading information is guilty off a felony.
Applicable PA
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.
Applicable in OR
Any person who knowingly and with intent to defraud or solicit another to defraud
the insurer by submitting an application containing a false statement as to any
material fact may be violating state law.
Applicable in VA
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 benefits.
FRAUD APPS (2019/11)
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Completed 20 July 2020

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