Special Events Liability Insurance

Policyholder Information

Fields marked with an asterisk (*) are required.

Policyholder

Full Legal Name:	*	(as it will appear on the policy documents)
Mailing Address:	*
City:	*
State:	* Select a state... AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip Code:	*

Contact Information

First Name:	*	Middle:		Last Name:	*
Phone:	*			Email Address:	*
				Agent Email:

Event Information

Fields marked with an asterisk (*) are required.

Specified Activity:

*

Date(s) and time(s)

First Day of Event:	*	Last Day of Event:	*
Additional information about dates of event:

Name and location

Name of Event:
Location of Event:
Website of Event:
Does the Location of Event have Liability Insurance?		Yes No
Estimated Daily Attendance:
Estimated Total Gross Receipts ($):
Description of Event:

Does the Event Include Alcohol?

Yes No

Alcohol

Provide Copies of any Marketing or Advertising Documents
Is Liquor to be Sold at this Event?	Yes No
May Patrons Bring their own Liquor?	Yes No
Total Estimated Alcohol Receipts per Day ($)
Estimated Number of Attendees Consuming Alcohol Daily
Is Applicant the Sole Vendor of Alcohol at the Event?	Yes No
If No, Please List Number of Vendors Serving Alcohol
Are all Participating Alcohol Vendors Required to Carry Liquor Liability Insurance?	Yes No
Is a Liquor License Required for the Event?	Yes No
Will Alcohol be dispensed by a Professional Bartender?	Yes No
Describe Training and/or Experience of Persons Serving Alcohol
What Preventive Measures Exist to Prevent Service of Alcohol to Minors and/or Intoxicated Persons?
Has the Applicant Received any Fines or Citations in the Last 5 Years?	Yes No

Does the Event Include Musical Entertainment?

Yes No

Musical Entertainment

Provide Copies of any Marketing or Advertising Documents
Names of Bands or Performers:
Type of Music:
Do the Bands or Performers have Liability Insurance?	Yes No
Who is Responsible for Stage Construction?

Does the Event Include a Parade?

Yes No

Parade

Provide a Copy of the Parade Route
Has the Parade Route been approved by the Local Authorities?		Yes No
Will the Parade Route be secured by Police?		Yes No
Are Parade Participants Permitted to Throw Objects?		Yes No
Objects to be Thrown

Does the Event Include Athletics?

Yes No

Athletics

Provide Copies of Participant Enrollment Forms
Number of Estimated Athletic Participants per Day
Yes No
Will Athletic Participants Sign Waivers and/or Release of Liability Forms?	Yes No

Does the Event Includes Motor Vehicles?

Yes No

Motor Vehicles

Provide Diagram of Event Facility
Is the Event Location Specifically Designed for this Activity?	Yes No
Are Barriers in place to Ensure Spectator Safety?	Yes No
What is the Distance Between Barriers and Spectators?
Will the Event Include Spectator Participations?	Yes No

Does the Event Includes Inflatable or Amusement Devices?

Yes No

Inflatable or Amusement Devices

Provide Description of Each Amusement Item
Does the Amusement Device Provider have Liability Insurance?	Yes No
Are the Amusement Device Operators provided Manufacturer’s Operating Manuals?	Yes No
Are the Amusement Device Operators at least 19 Years of Age?	Yes No
Do the Amusement Device Operators Test Equipment Prior to Day of Use?	Yes No
Do the Amusement Device Operators Monitor for Patron Alcohol Use?	Yes No
Will there be a Mechanical Bull Device?	Yes No
Will there be a Zip Line?	Yes No

Common Questions

How Many Vendors will be Present?
Does Each Vendor have Liability Insurance?	Yes No
Who is Responsible for Providing Security?
Is Security Armed or Unarmed?	Armed Unarmed
Are Fireworks or Pyrotechnics Involved in the Event?	Yes No
Will there be Overnight Camping?	Yes No
If Displaying Vehicles, will Vehicles Remain Stationary?	Yes No
Does the Applicant have a Risk Management Plan?	Yes No
Has Prior Insurance ever been cancelled?	Yes No
Have Claims Been Filed in the Past?	Yes No

Documents

Please Attach All Lease and Hold Harmless Agreements, Brochures of the Event and a Diagram of Location(s) to be Used.

Maximum file size: 4MB

Remove Remove Remove Remove Remove Remove Remove Remove Remove Remove Add

Acknowledgements and Signatures

Fraud Warning 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 may be a crime. Applicant’s Acknowledgement I, the applicant, declare, to the best of my knowledge and belief, that all statements and answers in this application are true and complete. I understand and agree that (a) this application will form part of any policy issued,(b) no information given to or acquired by any representative of the Company will bind it, unless it is in writing on this application,(c) no waiver or modification will bind the Company unless it is in writing and is signed by an executive officer of the Company, and (d) only those persons eligible under the terms of an issued policy will be insured.
To sign the application, check the Digital Signature checkbox below:
Digital Signature	*
User's Name