Fillable Special Event Product The Main Event (RT Specialty)

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Special Event Product The Main Event (RT Specialty)

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YOU CAN OBTAIN A QUOTE BY PROVIDING THE INFORMATION IN THE INSTANT QUOTE SECTION, SUBJECT TO THE REMAINDER PROVIDED PRIOR TO BINDING.
SELA-6/09
page 1 of 4
I. INSTANT QUOTE INFORMATION
Instant Quote is only available for accounts with no losses in the past three years. If there is loss history, please detail the losses below.
TYPE OF EVENT
Beer garden/Beer tent Fundraiser Individual vendor booth
 Car show Motor vehicle race/Show Picnic
Concerts/Musical performance Competition or shows Sporting event/Tournament
Conventions/Trade show/Exhibit Parade Wedding/Wedding reception
Festival Party/Social event Other (describe): ________________________
Name of applicant: _________________________________________________________________________________________________________
(List only one legal & dba name. Do not include “etal”, “etc.” or other similar wording in the name.)
Describe applicant’s role and responsibility in event: ___________________________________________________________________________
__________________________________________________________________________________________________________________________
Location address: ________________________________________________________________________________
Same as mailing address
City: ____________________________________________________ State: ______________________ Zip: ________________________
Dates of event: From: ______/ _________/ _______ To: _______/ _______/ _______
(If one day event, end date should be the same as start date. Quote will contemplate coverage for events continuing past 12:00 AM)
Desired coverage date(s): From: ______/ _________/ _______ To: _______/ _______/ _______
If event date(s) differs from desired coverage date(s), explain: __________________________________________________________________
Is set-up and take-down coverage needed for additional dates? Yes* No
*If “Yes,” what are the dates and what will this exposure include?
______________________________________________________________________________________________________________________
*Will there be any heavy machinery used such as bulldozer’s, backhoes, excavators, or any other types of industrial machinery
(small forklifts and light machinery are acceptable)? Yes No
Would you like to include a rain date? Yes* No *If “Yes,” what date? ___________________________________
FULL SCHEDULE/DESCRIPTION AND PURPOSE OF EVENT (Attach copy of brochure, website pages and flyer to this application or
include details on all activities taking place):___________________________________________________________________________________
__________________________________________________________________________________________________________________________
Will there be any entertainment? Yes* No
*If “Yes,” describe and include name of performers and acts: ________________________________________________________________
Is there a Web site for this event? Yes* No
*If “Yes,” provide Web site address: ______________________________________________________________________________________
Name of additional insured: _________________________________________________________________________________________________
Mailing address: ___________________________________________________________________________________________________________
Additional insured’s interest in event: _________________________________________________________________________________________
Coverage desired:
Commercial general liability and liquor liability Commercial general liability only Liquor liability only
Limits of coverage desired: _____________________________________________________________________________________________
COMMERCIAL GENERAL LIABILITY
ESTIMATED TOTAL ATTENDEES PER DAY: __________________
If applicant is an individual exhibitor/vendor, what is the estimated attendees per day anticipated to visit their booth? ______________
Average age of attendees: ______________________________________________________________________________________________
LIQUOR LIABILITY (IF COVERAGE IS DESIRED)
Hours of event: From: __________ AM/PM To: ________AM/PM
If hours vary by date, describe: ______________________________________________________________________________________
ESTIMATED NUMBER OF ATTENDEES CONSUMING ALCOHOL DAILY: ___________________________________________________
Is the applicant in the business of selling, serving or furnishing alcoholic beverages? Yes No
Is the applicant required to have a liquor license for the event (excluding licenses that are restricted to
a host liquor exposure where event sales are not for personal monetary gain)? Yes No
The Main Event
®
— Special Event Product
U
NITED
S
TATES
L
IABILITY
I
NSURANCE
G
ROUP
A BERKSHIRE HATHAWAY COMPANY
USLI.COM
888-523-5545
Submit Application
1. Previous carrier: _________________________________________ Policy number: ________________________________________________
2. Losses or claims during the past five years: ___________________________________________________________________________________
III. LIQUOR LIABILITY
1. a. Is applicant the sole vendor/server of alcohol at event? Yes No*
*If “No,” list number of other vendors/servers serving alcohol: _______________________________________________________________
b. If there are multiple vendors, are all participating alcohol vendors/servers required to carry liquor liability limits for the
event equal to or greater than our applicant? Yes No
2. Will alcohol be dispensed by a professional bartender or server that has taken a formal alcohol
awareness training course? Yes No
3. Will alcohol be sold by applicant? Yes No
4. Is BYOB (Bring Your Own Bottle) or self-service of alcohol permitted? Yes No
IV. COMMERCIAL GENERAL LIABILITY
1. Will event feature any of the following:
a. Mechanical rides/devices? Yes No
b. Moon bounce, rock climbing wall, trampoline or similar rebounding devices, petting zoo or animal rides? Yes * No
*(Please Note: Our policy specifically excludes injuries arising from moon bounces, trampolines, rock walls, petting zoos and pony rides).
c. Firearms or fireworks? Yes No
d. Overnight camping? Yes No
e. Water hazards? Yes* No
*If “Yes,” describe: _____________________________________________________________________________________________________
*Will attendees be permitted to swim, boat, jet ski or fish? Yes* No
*If “Yes,” describe: _____________________________________________________________________________________________________
2. Will the event use exhibitors, vendors, performers, contractors, sub-contractors or independent contractors? Yes* No
*(Please note, injuries arising from exhibitors, vendors, performers, contractors, sub-contractors or independent contractors
are excluded from our policy).
3. a. Describe security measures: ____________________________________________________________________________________________
b. If security is provided by independent contractors, are they required to carry their own insurance? N/A Yes No
4. If this is a CONCERT/MUSICAL EVENT, complete below: (Please note, coverage for injury to performers and entertainers is excluded
from our policy).
a. Name(s) of performer(s): ____________________________________________ Describe type of music: _____________________________
b. Performers are: Local National
c. Will pyrotechnics be featured? Yes No
d. Any special effects? Yes* No
*If “Yes,” describe: _____________________________________________________________________________________________________
5. If this is a PARADE EVENT, complete below: (Please note, coverage for injury to parade participants is excluded from our policy).
a. Has parade route been approved by local authorities and will route be secured by police? Yes No*
*If “No,” explain: _______________________________________________________________________________________________________
b. Are parade participants permitted to throw souvenirs, candy or other items into the crowd? Yes No
c. Describe parade route from start to finish: ________________________________________________________________________________
6. If this is an ATHLETIC EVENT, complete below: (Please note, coverage for injury to athletic participants is excluded from our policy).
a. Describe athletic event: ______________________________ b. Professional or Amateur
7. If this is a MOTOR VEHICLE RACE, RODEO, TRACTOR PULL OR TRUCK SHOW, complete below: (Please note, coverage for injury to
participants is excluded from our policy).
a. Is the venue designed specifically for this type of activity? Yes No
b. Are metal or concrete barriers in place to ensure spectator safety? Yes No*
*If no, describe:________________________________________________________________________________________________________
c. Are the barriers permanent? Yes No
d. How high are the barriers? ____________________ What is the distance between the barriers and spectators? ____________________
e. Are spectators ever permitted in the pit or infield area? Yes No
f. If this is a rodeo, are the transfer areas between animal pens and the competition restricted from the
general public? Yes No
g. Will the event feature audience participation (i.e. calf scrambles)? Yes No
SELA- 6/09 - United States Liability Insurance Group
page 2 of 4
II. HISTORY
8. If this is a HEALTH FAIR/CONVENTION, complete below:
a. Will the event feature any medical or health treatment? Yes No
9. If this is a CAR SHOW/MOTOR VEHICLE SHOW, complete below: (Please note, coverage for injury to participants is excluded from
our policy)
a. Do vehicles remain stationary throughout the show with the engines off? Yes No
b. Will the event feature burnouts, drag races or flame throwing? Yes No
V. ADDITIONAL APPLICANT INFORMATION
Form of business: Individual Corporation Partnership LLC Other ____________________________
Applicant’s mailing address: ____________________________________________________ (if different than the location address above)
City: ______________________________________________________ State: ______________________ Zip: ________________________
E-mail address of primary contact: _____________________________________________ Phone: ____________________________________
Virginia Notice: Statements in the application shall be deemed the insured’s representations. A statement made in the application or in any
affidavit made before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly proven that such
statement was material to the risk when assumed and was untrue.
Minnesota Notice: The clause “and/or authorization or agreement to bind the insurance.” is replaced with “Authorization or agreement to bind
the insurance may be withdrawn or modified based on changes to the information contained in this application prior to the effective date of
the insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10 days notice given to the
insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for
nonpayment of premium.
Colorado Fraud Statement: 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.
District of Columbia Fraud Statement: 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.
Florida Fraud Statement: You are agreeing to place coverage in the surplus lines market. Superior coverage may be available in the
admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act with
respect to any right of recovery for the obligation of an insolvent unlicensed insurer.
Kentucky Fraud Statement: 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.
Maine and Washington Fraud Statement: 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 a denial of insurance benefits.
New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is
subject to criminal and civil penalties.
New York Fraud Statement: 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.
Ohio Fraud Statement: 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.
Oklahoma Fraud Statement: 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 of a felony.
Pennsylvania Fraud Statement: 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.
Tennessee and Virginia Fraud Statement: 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 Statement (All Other States): 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 may be
guilty of a crime and may be subject to fines and confinement in prison.
SELA- 6/09 - United States Liability Insurance Group
page 3 of 4
Applicant’s signature: ____________________________________________ Title: _________________________ Date: _________________________
If your state requires that we have information regarding your authorized retail agent or broker, please provide below.
Retail agency name: _______________________________________________________________________ License #: ___________________________
Main agency phone number: ____________________________________________________________________________________________________
Agency mailing address: _________________________________________________________________________________________________________
City: ________________________________________ State: __________________ Zip code: ___________________________
SELA- 6/09 - United States Liability Insurance Group
page 4 of 4
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Completed 13 December 2020

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