Historic Theatre Application
General Information
First Named InsuredMailing Address / City / State / Zip
Contact Person / Phone: / Fax:
Web Address / Contact’s E-Mail Address:
Effective Date / Federal Tax I.D. # / Years in Business:
Payroll / Sales/Receipts
Are you currently a member of the League of Historic American Theatres?
Management/Ownership Information
Who occupies / manages the theatre? / Owner Tenant If you own the building, do you rent/loan it to others? / Yes No / The policy will not cover others who rent your facility; you may be able to purchase additional coverage at the time of each rental.
Are there emergency procedures in place? / Yes No
Do local authorities require inspection? / Yes No / If yes, how often?
Is there a written security procedure? / Yes No
Does management require Certificates of Insurance, with GL
limits of at least $1,000,000 from all Vendors, Suppliers
and Contractors / Yes No / PLEASE ATTACH A LIST OF ALL NAMED INSUREDS INCLUDING A DESCRIPTION OF EACH ENTITY
Does management require that all Vendors, Suppliers and
Contractors be named as Additional Insureds? / Yes No
Theatre Questionnaire
Are all performance participants covered by your worker’s compensation policy? / Yes No What type of performances (e.g., ballet, plays, etc.)?
Do you hold any performances away from the premises owned or leased by you?
If yes, as respects these performances:
- How many performances occur annually?
- What is the annual attendance?
- Do you provide ticket sellers, ticket takers or ushers for these performances?
- #______
- #______
- Yes No
As respects performances at premises owned or leased to you:
- How many performances occur annually?
- What is the annual attendance?
- #______
What is the seating capacity of the theatre?
Is the building fully or partially sprinklered? / Yes No
Are there curtains on stage? If yes, are they fire resistant? / Yes No
Are ushers utilized to assist patrons to seat during performances? / Yes No
Are aisles lighted? / Yes No
Is the theatre equipped with emergency lighting? / Yes No
Are exits lighted? / Yes No
Is there panic hardware on the exits? / Yes No
How many exits are there? / # ______
Is there emergency lighting in case of a power failure? / Yes No
Is there balcony seating? / Yes No
Is there a lowered pit near the stage? / Yes No
Are hydraulics or other mechanical means used to raise and lower stage sections? / Yes No
Do you operate a school or provide instruction to students?
If yes, indicate the number of students in each age group annually? / Yes No
_____1 - 12 _____13 - 18 _____19 +
Do you teach classes that are open to the public? / Yes No
Basic Coverage Detail
Is there a refreshment or concession stand operated by you? If yes, what are the grossannual sales? / Yes $______No
Is cooking done on premises? / Yes No
Do you serve alcohol? If yes, what are the gross annual sales? / Yes $______No
Do you hold special events/fundraisers? {Coverage for special events is not automatic.
Some events cannot be added at all. Coverage for others can be added as needed}
If yes, please attach a list of events/fundraisers including the name, dates and what
the event entails (e.g., music, food, alcohol, auctions, rides, ticket sales,
# of attendees, etc.) / Yes No
Do you currently have Directors and Officers Liability Insurance? / Yes No
Do you have volunteers? If yes, how many do you have annually? / Yes #_____ No
Do you currently have Accidental Death and Dismemberment Insurance for those Volunteers? / Yes No
If facility is rented to others for events such as meetings, weddings or receptions, what is the
annual income from these events? / $______
General Liability Coverage
Coverage / Limit
General Aggregate / $
Products & Completed Operations / $
Per Occurrence / $
Personal & Advertising Injury / $
Damage to Rented Premises / $
Medical / $
Hired & Non-Owned / $
Liquor Liability / $
Other : / $
Class Code / Description / Premium Basis Amount / Exposure
Inland Marine Coverage
Coverage / Limit / Co-Insurance / Valuation / Deductible / Special
Conditions / Blanket Coverage
Y/N
Marquis
Sound Equipment
Lighting Equipment
Wurlitzer
Stained Glass
Fine Arts
Chandeliers
Theatrical Property *
Signs
Other
* Theatrical Property: Limit includes items such as costumes, sets, props, etc.
Property Coverage
Location # Building #
LocationAddress / City / State / Zip
Year: / Construction: / Sq. Ft. / Stories: / Basement / Yes No
Updates / Roof / Electric/Wiring / Heating / Plumbing / Other:
Year: / Year: / Year: / Year: / Year:
Materials: / Materials: / Materials: / Materials: / Materials:
Boiler / Yes No / Distance to Fire Hydrant / ft / Fire Station / miles / Sprinklered / %
Fire Alarms / Yes No / Manufacturer: / Central Station Local Gong
Smoke Detectors / Yes No / Fire Extinguishers / Yes No / District Name:
Burglar Alarm / Yes No / Manufacturer: / Central Station Local Gong
LIMITS
Coverage / Limit / Co-Insurance / Valuation / Deductible / SpecialConditions / Blanket Coverage
Y/N
Building
Business Personal Property
Business Income with or
w/out Extra Expense
Computers
Other
If more than one location, please complete:
Property Coverage
Location # Building #
LocationAddress / City / State / Zip
Year: / Construction: / Sq. Ft. / Stories: / Basement / Yes No
Updates / Roof / Electric/Wiring / Heating / Plumbing / Other:
Year: / Year: / Year: / Year: / Year:
Materials: / Materials: / Materials: / Materials: / Materials:
Boiler / Yes No / Distance to Fire Hydrant / ft / Fire Station / miles / Sprinklered / %
Fire Alarms / Yes No / Manufacturer: / Central Station Local Gong
Smoke Detectors / Yes No / Fire Extinguishers / Yes No / District Name:
Burglar Alarm / Yes No / Manufacturer: / Central Station Local Gong
LIMITS
Coverage / Limit / Co-Insurance / Valuation / Deductible / SpecialConditions / Blanket Coverage
Y/N
Building
Business Personal Property
Business Income with or
w/out Extra Expense
Computers
Other
Property Coverage
Location # Building #
LocationAddress / City / State / Zip
Year: / Construction: / Sq. Ft. / Stories: / Basement / Yes No
Updates / Roof / Electric/Wiring / Heating / Plumbing / Other:
Year: / Year: / Year: / Year: / Year:
Materials: / Materials: / Materials: / Materials: / Materials:
Boiler / Yes No / Distance to Fire Hydrant / ft / Fire Station / miles / Sprinklered / %
Fire Alarms / Yes No / Manufacturer: / Central Station Local Gong
Smoke Detectors / Yes No / Fire Extinguishers / Yes No / District Name:
Burglar Alarm / Yes No / Manufacturer: / Central Station Local Gong
LIMITS
Coverage / Limit / Co-Insurance / Valuation / Deductible / SpecialConditions / Blanket Coverage
Y/N
Building
Business Personal Property
Business Income with or
w/out Extra Expense
Computers
Other
Workers Compensation
Number of Employees: ______Full Time ______Part Time
Annual Payroll:
Description of employee duties:
Umbrella
Limit of Liability: ______
Self Insured Retention: ______
Prior Policy Information
General Liability Policy
Year / Company / PremiumProperty Policy
Year / Company / PremiumUmbrella / Excess Liability Policy
Year / Company / PremiumOther Policies
Year / Company / Premium / YearLoss Experience: Please provide 3 years of hard copy loss runs from the insuring companies.