Civic and Convention Centers

CIVIC AND CONVENTION CENTERS

VENUE (NON-SPORTS) INSURANCE APPLICATION

BROKER INFORMATION

Broker/Agency Name:
Contact Person:
Address:
City / State / Zip
Phone: / Fax:
E-mail Address: / Website:

GENERAL INFORMATION

1.Applicant: / Proposed Effective Date:
Address:
Street / City / State / Zip
2.Contact person: / Website address:
Telephone: / Fax:
3.Please describe the operation of each named insured and their relationship to the first named insured (use separate sheet if necessary):
4.Location address of the first named insured (if same as applicant, mark same):
Address:
Street / City / State / Zip
5.Proposed insured is a (check one): Corporation Partnership
Individual Other (specify):
6.Is the proposed insured a subsidiary of another company? Yes No
If yes, name of parent company:
7. / Est. Annual
Sales Receipt / Est. Annual Admissions / Annual Payroll / No. of Employees / No. of Years In Business
Domestic:
Foreign:
Provide information regarding ownership of the facility:
8.Is named insured involved in the sale or distribution of any products? Yes No
If yes, please explain:
9.List all Additional Insureds including complete address and an explanation of the relationship to the Named Insured that requires the additional insured status. Complete information on attachment.
10.Date stadium/venue was constructed: / Date of any major reconstruction:
Primary construction material(s): / Stadium/venue capacity:
Permanent seating capacity: / Total Capacity:
Percent of facility that is sprinklered: / Type of siren/smoke alarms:
11.Are there any amusement rides, air inflatable structures, rock climbing walls, etc. on premises or brought on premises temporarily? Yes No
If yes, please describe:
12.Any childcare services provided? Yes No
If yes, please describe:
13.Has an emergency/contingency plan been promulgated? Yes No
If yes, please provide copy.
14.Provide a copy of current audited financials.
15.Please specify who has responsibility for the following event day operations:
Facility Maintenance / Facility / Subcontractor
Installation and Maintenance of Competition Area
(for sports events)
Concessions - Non Alcohol
Concessions - Alcohol
First Aid
Parking
Security**
Premises Defects
* Please provide all copies of subcontractor agreements
16. Person responsible for general operation of facility activities:
Number of years current management has operated this facility:
17. Provide a copy of the previous year’s calendar of events along with anticipated events proposed during the course of the upcoming policy period.
18.Any self-promoted events?YesNo
LIABILITY COVERAGES AND LIMITS REQUESTED
Limit
19.Commercial General Liability: / $
General Aggregate: / $
Products and Completed Operations (aggregate): / $
Personal and Advertising Injury: / $
Damage to Premises Rented to You: / $
Self-Funded retention: / $
20.Other coverage needs:
CONTRACTUAL
21.Provide copies of standard lease agreements and actual leases of multi-event tenants. Also provide details of other contractual agreements.
22.Do entities using the facility list the proposed named insured as an additional insured? Yes No
If yes, what limit is required?
23.For instances where subcontractors are utilized, is the proposed named insured listed as an additional insured
under the subcontractor’s policy? Yes No
24.Who has authority to sign contracts on behalf of the proposed named insured and what is the review process?
25.Is there a system in place for obtaining certificates of insurance where applicable? Yes No
If yes, who reviews certificates on behalf of named insured?
What is the minimum limit of general liability coverage requested from each subcontractor?

RESTAURANT/FOOD SERVICE OPERATIONS

26.Are cooking installations in compliance with NFPA 96? Yes No
27.Are all cooking surfaces protected by automatic fire extinguishing systems? Yes No
28.Is automatic fire extinguishing systems serviced by outside contractor? Yes No
If yes, frequency of service: / Date last serviced:
29.Are hoods/duct work cleaned by outside service contractor? Yes No
If yes, frequency of service: / Date last serviced:

A.EMPLOYEE BENEFITS LIABILITY

(Please complete this section if you need a quote for Employee Benefits Liability Coverage. If you do not need a quote for Employee Benefits Liability, please skip this section and continue to the next section.)

30.Does applicant have a full-time Personnel Department? Yes No
31.Number of employees under Employee Benefit Program administered in the United States Canada
32.Employee Benefit Programs which are automatically covered without being specifically listed by the applicant are (check all that apply):
Group Life Insurance / Group Accident or Health Insurance / Profit Sharing Plans / Pension Plans
Employee Stock Subscription Plans / Workers' Compensation / Unemployment Insurance
Disability Benefits Insurance / Social Security Benefits
33.List below any other types of benefit programs the applicant wants the company to consider for inclusion under this insurance:
Type of Benefit Program
34.On programs permitting employees an option to enroll or not to enroll, does the applicant require a signed acceptance or rejection from each employee? Yes No
If yes, is the signed acceptance or rejection retained in the employee's personnel file? Yes No
35.Is a benefit brochure or written explanation of the Employee Benefits Program given to each employee? Yes No
36.Are all benefits available to all employees? Yes No
If no, list all exceptions:
37.Who advises the employees of their benefits?
Personnel Manager / Department Manager / Immediate Supervisor
Other (Please describe):
38.Is there a review of employee questions and a record kept as to each employee's acceptance or rejection of any one or all the benefits? Yes No
39.Has any Error and Omission loss ever been sustained or is any such claim pending against the applicant?
Yes No
If yes, please give details:
40.Has any occurrence taken place in the past that is likely to give rise to a claim? Yes No
If yes, please give details:
41.Number of branches, other business locations:
How are employees in branches and other locations advised of benefits?
42.What is the first date any previous Employee Benefits Liability coverage was carried?
B.ABUSE AND MOLESTATION
(Please complete this section if you need a quote for Abuse and Molestation Coverage. If you do not need a quote for Abuse and Molestation, please skip this section and continue to the next section.)
43.Does the insured have custodial responsibility for minors? Yes No
If yes, is abuse coverage desired? Yes No
44. Do your employees and volunteers (paid and volunteer) employment application include questions about whether the individual has ever been convicted for any crime, including sex-related or child-abuse offenses?
Yes No
If yes, what is the process for dealing with a "yes" answer?
45.(a)Does your state permit you to do criminal background checks on:
Yes No Employees?
Yes NoVolunteers?
(b)If yes, do you routinely request and receive such background information on all individuals who will have contact with minors? Yes No
46.(a)Do you verify employment-related references for employees? Yes No
(b)Do you verify employment-related references for volunteers? Yes No
47.(a)Do you conduct a personal interview for employees? Yes No
(b)Do you conduct a personal interview for volunteers? Yes No
48.Do you have a written set of procedures for screening employees and volunteers? Yes No
If yes, please forward. If no, please describe your screening process.
49.Do you have an Abuse / Molestation Policy with regard to sexual abuse? Yes No
If yes, please indicate how it is transmitted to your employees/volunteers.
50.Do you have written procedures for dealing with allegations of sexual abuse? Yes No
If yes, please forward. If no, please describe what your current response would be.
51.Describe how your organization supervises employees and volunteers having custody of children.
52.Describe specific policy regarding any overnight travel.
53.(a) Has your organization ever had an incident which resulted in an allegation of sexual abuse? Yes No
If yes, please describe your organization's response to the allegation.
(b) Was a claim made against the organization or an individual within the organization? Yes No
When did the alleged incident(s) occur?
(c) Was the case taken to trial? Yes No / Civil Criminal
(d) What was the disposition of the case?
54.Regarding coverage for abuse and molestation, does your current insurance program:
Yes NoExclude coverage?
Yes NoLimit coverage (please forward a copy of the endorsement)?
Yes NoNeither exclude or limit coverage?
55.Please indicate age range of minors in your care or under the supervision of your employees or volunteers at any time.
56.Please describe your current and/or planned operations that involve the custodial care of minors.

C.LIQUOR LIABILITY

(Please complete this section if you need a quote for Liquor Liability Coverage. If you do not need a quote for Liquor Liability, please skip this section and continue to the next section.)

57.Name on liquor license:
58.Liquor license number: / Class of license:
59. Type of facility or event where liquor will be sold:
Dates coverage required:
Opening and closing hours of event(s):
Opening and closing hours of liquor sales:
60.Has applicant's liquor license ever been revoked or suspended? Yes No
If yes, please explain:
61.Has applicant incurred claims for liquor liability during the last 3 years? Yes No
If yes, please explain:
62.Has any insurer cancelled or non-renewed coverage during the last 3 years? Yes No
If yes, please explain:
63.Has applicant ever been fined by alcoholic beverage control or other governmental regulator? Yes No
If yes, please explain:
64.Type of beverages sold:
65.Annual Gross Sales:
Liquor Sales $
Food Sales$
Other$
66.Are patrons allowed to carry alcoholic beverages onto the premises? Yes No
If yes, what type?
67.Do you exercise the right of search and seizure of contraband items? Yes No
If yes, how do you notify the public of this?
68.Do you maintain security personnel at entry check points? Yes No
If yes, what type?
Are69.69.Are the alcohol sales and consumption:
Contained within one fixed site, or Are booths/stands located throughout the event site?
70.Number of servers used?
Professional? Yes No Explain:
Volunteer? Yes No Explain:
71.Do the servers receive any type of alcohol awareness training? Yes No
If yes, please explain:
(attach training manuals used)
72.Median age of liquor customers: 21-25 25-30 30-40 40 and over
Are minors allowed to enter the location where alcohol is being served? Yes No
If yes, how is underage consumption of alcohol prevented?
73.Explain how ID's are checked:
74.Are uniformed police officers present at the site of alcohol sales? Yes No
If yes, how many?
Are undercover police officers present? Yes No
If yes, how many?
Are private security officers present? Yes No
If yes, how many?
75.Are rules and regulations clearly displayed for patrons viewing? Yes No
Describe:
76.In what size of container is the alcoholic beverage served? Cup oz. Pitcher Other
77.Is there a limit placed on the quantity of alcoholic beverages purchased at one time? Yes No
Explain:
78. Is there entertainment provided? Yes No
Live music? Yes No
Disc Jockey? Yes No
Type of music:
79.Is the parking area patrolled to prevent intoxicated drivers from leaving the premises? Yes No
Explain:
80.Is there any type of designated driver program? Yes No
Explain:
81.Is there any other underlying liquor liability coverage being provided? Yes No
Explain:
82.Will there be additional limits of liquor liability purchased? Yes No
If yes, what is the additional limit?

D.SECURITY COVERAGE

(Complete only if security is the responsibility of the insured.)

PART I
83.Who is primarily responsible (via contract) for liability coverage for security personnel?
Insured Municipality Subcontractor
Number of security personnel on staff:
Number of security supervisors:
Number on premises:
Number off premises:
84.Do any security personnel carry a firearm as part of their equipment while on duty? Yes No
If yes, number of armed security personnel:
85.Are the security persons employed or contracted by the park? Employed Contracted
("Employed" means the individual is being paid and supervised directly by the insured. "Contract" means the existence of a written contract with another entity for security services that has insurance coverage separate from the insured's policy for security liability.)
Note:If "Employed," please answer Section B., Part I, II, III, and V.
If "Contracted," please answer Section B., Part I, II, III, IV, and V.
86. If applicable, please provide the estimated payroll for employed security persons.
87.Total maximum hours per day permitted at this and all other places of employment:
Total maximum hours per week?
88.What are the staffing guidelines per number of patrons?
89.Are the guidelines determined by: Ordinance, or Statute?
Industry standard? Yes No
Other (please describe):
PART II:
90.Is there a pre-employment screening procedure? Yes No
If yes, please describe:
91.Does the procedure include contacting previous employers over the previous five years? Yes No
92.Do you contact at least three personal references? Yes No
93.Is a psychological screening profile used? Yes No
If "yes," what type:
94.Is a criminal background check made? Yes No
If "yes," what agency is used for the criminal background check?
95.Is completion of a minimum 20 hours initial training program required before deployment? Yes No
96.Who conducts the training and what are the trainers qualifications:
97.Is a minimum of 10 hours on-site training required? Yes No
98.Is a minimum of 4 hours of annual refresher or continuing education training planned and conducted for each security employee? Yes No
99.Is each security person given a personal copy of the training/safety manual? Yes No
If "yes," has each security person given the park written acknowledgment of the policies and contents?
Yes No
NOTE: PLEASE INCLUDE A COPY OF THE MANUAL & A SAMPLE OF THE WRITTEN ACKNOWLEDGMENT.
PART III:
100.Are the security personnel in uniform? Yes No
If "yes," please describe the uniform:
NOTE: PLEASE ATTACH A PHOTOGRAPH OF ONE SECURITY PERSON IN STANDARD UNIFORM.
101.Are the security personnel identified by other than a uniform? Yes No
If "yes," please describe the identification and include an example or photograph.
102.Please indicate any equipment carried or routinely available to security personnel:
Flashlight / Type: / Size: / Construction:
HandcuffsNight Stick (Is Night Stick Police Regulation? Or Other?)
First Aid Kit (including blood borne pathogen kit)
Taser/PhaserChemicals (Mace, pepper gas)
Other:
Firearm - Caliber:.357.38.9mmOther:
Make:ColtS&WRugerOther:
Covered HolsterType:
Is AmmunitionStandardOther:
Firearm and ammunition approved and inspected by park or security company? Yes No
103.Describe capabilities of each guard for constant communications with each other, the supervisor, and park
management:
104.Are dogs used in your security operations? Yes No
If yes, please provide the type of dog(s), number, and describe duties.
PART IV:
105.Date the contracting company began business:
106.Is there a written agreement with contracting company? Yes No
If "yes," Please enclose a complete copy of the written agreement
107.Name of contracting company's liability insurance carrier:
108.Is the park an additional insured on that policy? Yes No
If "yes," please enclose a complete copy of the policy.
109.Is there an established working relationship with local law enforcement? Yes No
If "yes," please describe:
110.Please attach a copy of the contracting company's employment procedures.
111.No. of contracted security personnel: / No. of security supervisors:
112.Are there any suits or legal actions pending against the company? Yes No
If yes, please explain in detail:
113.Is there a procedure to immediately report all incidents to park? Yes No
If yes, please describe:
PART V:
114.Does the supervisor make personal contact with each security person at least once during each shift?
Yes No
If "yes," please describe:
115.Please explain all "no" answers.

E.PYROTECHNICS

(Please complete this section if you need a quote for Pyrotechnics Coverage. If you do not need a quote for Pyrotechnics coverage, please proceed to the next section)

116. Limit of liability requested: $1,000,000 Other:
117. Description of Events:
118. Location of Events:
Street / City / State / Zip
119. Dates of Events:
120.Who is the Authority having jurisdiction over the use of pyrotechnics at your facility?
Local Fire Department State Fire Marshal Other (please list):
121.What permit process must be followed prior to use of pyrotechnics at your facility:
122.Please submit the pyrotechnics plan from the most recent use of pyrotechnics for which a permit was obtained.
123.Have you staged pyrotechnic displays before? Yes No
If yes, please list any claims/losses that have occurred and the amount of loss:
Description / Date of Occurrence / Amount of Loss
A.
B.
C.
124.Who will be the pyrotechnics operator?: Named Insured Contractor
Complete this section if thePyrotechnics Operator is the Named Insured
(a) List names of people shooting fireworks and describe their experience.
Please note: This coverage will exclude Bodily Injury Liability to the fireworks shooter.
Name / Experience
(b)Where are the pyrotechnics stored when not in use?
Does it meet Federal/State Storage Regulation? Yes No
What quantity of pyrotechnic material is stored on site (pounds, # of shows, etc):
Describe the type and amount of pyrotechnics used in recurring events (e.g. facility introductions, home runs, etc.):
Describe what fire prevention and suppression measures are taken to support the pyrotechnic loading and firing
process:
Do you secure proper pyrotechnic permits for each event? Yes No
Are the shooters listed above licensed for pyrotechnics? Yes No
Complete this section if thePyrotechnics Operator is a Contractor.
(a)Name:
(b)Is there an agreement with the contractor? Yes No
If yes, please provide a copy of the agreement.
(c)Will liability coverage be provided by the pyrotechnics contractor? Yes No
If yes, please indicate limits of coverage provided:
$1,000,000 Greater than $1,000,000 Other:
Please attach a copy of certificate of insurance including any additional insured listing
(d)Do you confirm that the contractor has secured the proper pyrotechnic permits for each event?
Yes No
(e) Describe what fire prevention and suppression measures are taken to support the pyrotechnic loading and firing process:
(6)
87. 125.Do you allow tenant users (including temporary tenant users) to conduct pyrotechnic displays either themselves or through a contractor? Yes No
If yes, what steps are taken to ensure that the appropriate permits are granted, appropriate fire safety codes are
met, and that insurance has been obtained from either the tenant or the tenant’s contractor which lists you as an
Additional insured?
If no, does the tenant lease/use agreement indicate that pyrotechnic displays are not permitted? Yes No
126. Are events with pyrotechnics held: Indoors Outdoors
127.What type of pyrotechnics will be displayed (as defined in NFPA code 1126)?
Aerial Shells Airbursts Black Powder Comets
Concussion Effects Concussion Mortars Electric Matches Flares
Flash Pots Flashpowder Gerbs Integral Mortars
Mines Mortars Rockets Saxons
Waterfall, Falls, Park Curtains Wheels Salutes
Other, please list:
OUTDOOR PYROTECHNICS (only complete if outdoor pyrotechnic displays are staged)
128.Are the events in compliance with NFPA 1123 or 1126 (Code for Fireworks Display)? Yes No
129.Is there fencing to keep spectators away from restricted areas during the fireworks shooting? Yes No
If yes, distance of spectator fencing from launch site:
Distance of spectator parking area from launch site:
Distance of closest building or structure from launch site:
130.Will there be firefighting equipment on site during the event? Yes No
131.If no firefighting equipment on site, give distance to nearest fire station:
132.Will you have an ambulance on site? Yes No
If no,(a) what is the estimated response time of an ambulance?
(b) distance to nearest medical facility:
INDOOR PYROTECHNICS (only complete if indoor pyrotechnic displays are staged)
133.Are the events in compliance with NFPA 1126 (Standard Code for the Use of Pyrotechnics before a Proximate Audience)? Yes No
134.Is the facility sprinklered? Yes No
135.What other form of fire fighting equipment is available at the facility?
136.Does the facility have an emergency evacuation plan? Yes No
If yes, how often is the staff drilled on emergency evacuation?
137.Number of accessible (not locked) emergency exits at the facility:
138.What steps are taken to inform patrons of the locations of all emergency exits?
139.Maximum capacity of the facility:
140.Has the fire marshal approved the use of pyrotechnics at the facility? Yes No
If yes, as of what date:

F.AUTOMOBILE AND TRANSPORTATION INFORMATION