Fillable Special Event Product Application (Abram Interstate Insurance)

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Special Event Product Application (Abram Interstate Insurance)

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PF-47424 (01/16)
ACE Group
Commercial
Risk Services
Page 1 of 5
Special Event Product Application
GENERAL
APPLICANT
INFORMATION:
Applicant’s
name:
_____
Location address for event:
____
City:
State:
Zip:
Mailing
address:
City:
State:
Zip:
Name of primary contact:___________________________Email address of primary contact:__________________
Phone number: _______________________________________
TYPE OF EVENT
:
☐Festival/Fair ☐Individual Vendor Booth ☐Sporting Event/Tournament
☐
Concerts/Musical Event
☐
Parade
☐Theater Performance
☐Convention/Trade Show ☐Wedding ☐
Party/Picnic/Social Event
☐
Competition/Show
☐
Motor Vehicle Race/Show
☐
Beer Garden, Beer Tent
☐
Rodeo
☐
Fundraiser (describe):
☐
Other (describe):
Full description of event activities:
Describe applicant’s role or interest in event:
COVERAGE REQUESTED
:
☐General Liability and Liquor Liability ☐General Liability Only ☐Liquor Liability Only
DESIRED LIABILITY LIMITS:
☐
$300,000/$300,000
☐
$500,000/$1,000,000
☐
$1,000,000/$3,000,000
☐
$300,000/$600,000
☐
$1,000,000/$1,000,000
☐
$2,000,000/$2,000,000
☐
$500,000/$500,000
☐
$1,000,000/$2,000,000
☐
$3,000,000/$3,000,000
DATES OF EVENT: Start date _____/______/______ End date _____/_____/_____
Is Set-up coverage required? Yes ☐ No ☐
If yes, list dates____________________________________________________________________
Is Takedown coverage required? Yes ☐ No ☐
If yes, list dates____________________________________________________________________
Is Rain Date coverage needed? Yes ☐ No ☐
If yes, provide alternate date(s) for event:________________________________________________
Will event end after 2:00 am on any day? Yes ☐ No ☐
If yes, provide details:______________________________________________________________
PF-47424 (01/16)
ACE Group
Commercial
Risk Services
Page 2 of 5
UNDERWRITING ELIGIBILITY:
1. Any use of heavy machinery such as bulldozers, backhoes, cranes, excavators or
similar equipment? Yes ☐ No ☐
2. Does event feature overnight camping, bonfires, swimming, boating, jet skis or on-water fishing? Yes ☐ No ☐
ADDITIONAL INSUREDS:
Name
Interest
Mailing Address
Is Primary and Non-contributory wording needed? Yes ☐ No ☐
If yes, list number of contracts needed: ___________________________________________________
Is Waiver of Subrogation needed? Yes ☐ No ☐
If yes, list number of contracts needed: __________________________________________________
LOSS HISTORY:
Date of Loss
Description of Loss
Open/Closed?
Amount Paid
GENERAL LIABILITY UNDERWRITING
INFORMATION:
1. Estimated number of attendees per day_____________________________
If applicant is operating an individual vendor booth, list estimated attendees expected at booth:__________
2. Does the event feature any of the following:
a. Mechanical or carnival rides or devices? Yes ☐ No ☐
b. Fireworks, firearms or pyrotechnics? Yes ☐ No ☐
c. Haunted houses or hayrides? Yes ☐ No ☐
d. Hot air balloon, helicopter or airplane rides? Yes ☐ No ☐
e. Celebrities or high-profile attendees? Yes ☐ No ☐
If yes, please list:_________________________________________________________
3. Is security provided? Yes ☐ No ☐
If yes, and security is provided by independent contractors, are they required to carry their own
liability insurance? Yes ☐ No ☐
4. Will the event feature any medical or health screenings/treatment? Yes ☐ No ☐
LIQUOR LIABILITY UNDERWRITING
INFORMATION:
1. Estimated number of attendees consuming alcohol per day________________________
2. Is the applicant an individual or business that regularly sells, serves or furnishes alcohol? Yes ☐ No ☐
3. Will the alcohol be sold or served by a professional bartender with formal alcohol server training? Yes ☐ No ☐
4. Will the applicant be selling alcohol at the event? Yes ☐ No ☐
5. Is self-service or BYOB (bring-your-own-bottle) permitted? Yes ☐ No ☐
ELIGIBILITY BY EVENT TYPE – complete if applicable:
Wedding
1. Is applicant (who is hosting the wedding), in the business of selling, serving or furnishing alcohol and/or
required to purchase a liquor license for the event? Yes ☐ No ☐
2. Is a caterer or professional bartender serving the alcohol at the event? Yes ☐ No ☐
3. Does applicant require coverage for a rehearsal dinner? Yes ☐ No ☐
If yes, provide date: ____/_____/_____
PF-47424 (01/16)
ACE Group
Commercial
Risk Services
Page 3 of 5
Optional coverages (eligible wedding events only):
Type Of Coverage
Limit Needed
Maximum Limit Available
Cancellation or Postponement Coverage
$
$50,000
Photographs or Video Coverage
$
$10,000
Event Gift Coverage
$
$10,000
Damage to Wedding Attire ($1,000 included automatically)
$
$10,000
Loss of Deposits ($1,000 included automatically)
$
$10,000
Scheduled Jewelry Coverage
Item Description_________________________
Item Description_________________________
Item Description_________________________
Item Description_________________________
$____________________________
$____________________________
$____________________________
$____________________________
$10,000 total
Concert/Musical Event
1. Check type of music featured: ☐ Rock ☐ Country ☐ Hip-hop/Rap ☐ Gospel ☐ Heavy Metal
☐ Folk/Cultural ☐ Jazz/Blues ☐ Orchestra
☐ Other (describe):____________________
2. Are performers known on national level? Yes ☐ No ☐
3. List name(s) of performer(s): ______________________________________________________________
Sporting/Athletic Event
1. Describe type of event:___________________________________________________________________
2. Does event involve professional athletes? Yes ☐ No ☐
If yes, list the athletes’ names:___________________________________________________________
3. Does event include an obstacle course, mud run, trail run or off-road course? Yes ☐ No ☐
Motor Vehicle Race, Rodeo, Tractor Pull or Truck Show
1. Is the venue designed specifically for this type of event? Yes ☐ No ☐
2. Are permanent barriers made from metal, concrete or similar material in place to protect spectators? Yes ☐ No ☐
3. List height of the barriers: ____________feet
4. Are spectators permitted in the infield or pit areas? Yes ☐ No ☐
5. Will the event allow audience participation in the ring/infield? Yes ☐ No ☐
6. Does event include an obstacle course, mud run, trail run or off-road course? Yes ☐ No ☐
7. Does event feature drag racing, flame-throwing or burnouts? Yes ☐ No ☐
Car Show or Motor Vehicle Show
1. Do vehicles remain in stationary during the event? Yes ☐ No ☐
2. Does event feature drag racing, flame-throwing or burnouts? Yes ☐ No ☐
PF-47424 (01/16)
ACE Group
Commercial
Risk Services
Page 4 of 5
Fraud Warning Statements:
NOTICE TO ALABAMA APPLICANTS: 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.
NOTICE TO ARKANSAS, LOUISIANA, RHODE ISLAND AND WEST VIRGINIA APPLICANTS: Any person who knowingly presents a
false or fraudulent statement for payment of a loss or benefit or knowingly presents false information in an application in insurance is
guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO COLORADO APPLICANTS: 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 defrau
d 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.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: W ARNING: 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, the insurer may
deny insurance benefits, if false information materially related to the claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: 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.
NOTICE TO KANSAS APPLICANTS: 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 any insurance policy for commercial or personal
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 materially false information concerning any fact material thereto; or conceals, for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act.
NOTICE TO KENTUCKY APPLICANTS: 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.
NOTICE TO MAINE APPLICANTS: 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 or denial of insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a
loss or benefit or who 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.
NOTICE TO MINNESOTA APPLICANTS: A person who submits an application or files a claim with intent to defraud or helps commit a
fraud against an insurer is guilty of a crime.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an
insurance policy is subject to criminal or civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: ANY PERSON WHO KNOW INGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR
PAYMENT OF A LOSS OR BENEFIT OR KNOW INGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE
IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person
files and 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 be subject
to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against any
insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: W ARNING: 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 of
a felony.
NOTICE TO OREGON APPLICANTS: Any person who knowingly and with intent to defraud an 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 fraudulent insurance act, which may be a crime and
may subject the person to criminal and civil penalties.
PF-47424 (01/16)
ACE Group
Commercial
Risk Services
Page 5 of 5
NOTICE TO PENNSYLVANIA APPLICANTS: 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.
NOTICE TO VERMONT APPLICANTS: Any person who knowingly presents a false statement in an application for insurance may be
guilty of a criminal offense and subject to penalties under state law.
NOTICE TO TENNESSEE, VIRGINA AND WASHINGTON APPLICANTS: 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.
NOTICE TO ALL OTHER APPLICANTS:
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 INFORMATION FOR THE PURPOSE OF MISLEADING, COMMITS A FRAUDULENT INSURANCE
ACT, WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
Applicant’s Signature: _________________________________________________________________________
Title of Applicant: _____________________________________________________________________________
Date: ___________________________
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Special Event Product Application (Abram Interstate Insurance)

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Completed 10 July 2021

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