Event - Liability Insurance Application
Name of Applicant ______
Address of Applicant ______
______
Phone Number ______
Email Address ______
Dates of Events (if more than 6 dates, just enter start and end date) ______
______
Time(s)______
Name of Event ______
Location of Event ______
Name of Facility if other than above ______
Description of Event ______
______
______
Is this Event Located Indoors or Outdoors? ______
If Outdoors, ss the Area Fenced or Enclosed? _ Yes _ No
Are you Responsible for Parking? _ Yes _ No
If Yes, Square Footage of Parking Area ______
What is the Seating Capacity of the Event (if applicable)? ______
What is the Price of Admission? ______
What is the Estimated Attendance Per Day? ______What is the Estimated Gross Receipts?______
What is the Estimated Total Payroll? ______
What is the Number of Tickets Printed? ______
What is the Number of Tickets Sold to Date? ______
What are the Limits of Liability Requested?
$______Each Occurrence $______General Aggregate?
$______Medical Payments $______Fire Damage
$______Products Aggregate $______Personal/Adv Injury
Name, Address and Relationship of all Additional Insureds to be Added to the Policy:
1.) ______
2.) ______
3.)______
Will there be any Exhibitions, Demonstrations, Parades or Pageants? _ Yes _ No
If Yes, Please Describe______
Are Seats of Temporary or Permanent Construction(if applicable)? ______
Is Seating Reserved or General Admission (if applicable)?______
Describe Type of Seating Provided (Bleachers, Folding Chairs, etc.)(if applicable)______
If a Stage is Involved, is the Stage of Temporary or Permanent Construction?______
If Temporary, Who is Responsible For Set up of Stage? ______
______
If Other than the Applicant, is a Certificate of Insurance Provided? _ Yes _ No
If Other than the Applicant, is Applicant Named as Additional Insured? _ Yes _ No
Is a Tent Involved? _ Yes _ No
If Yes, Who is Responsible for the Set Up of the Tent? ______
If Other than the Applicant, is a Certificate of Insurance Provided? _ Yes _ No
If Other than the Applicant, is Applicant Named as Additional Insured? _ Yes _ No
Will Inflatables be Present at the Event?______
Who is Providing the Food and/or Drink?______
If Other than the Applicant, is a Certificate of Insurance Provided? _ Yes _ No
If Other than the Applicant, is Applicant Named as Additional Insured? _ Yes _ No
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Is Liquor to be Sold at this Event? _ Yes _ No
If Yes, Complete the following Questions if you would like a Quotation for Optional Liquor Liability Coverage.
Estimated Number of Attendees Consuming Alcohol Daily?______
Is Applicant the Sole Vendor of Alcohol at the Event? _ Yes _ No
a. If No, Please List Number of Vendors Serving Alcohol______
b. Are all Participating Alcohol Vendors Required to Carry Minimum Liquor Liability Limits for this Event? _ Yes _ No
Will Alcohol be dispensed by a Professional Bartender? _ Yes _ No
a. If No, Describe How and By Whom Alcohol will be Dispensed______
b. Describe Training and/or Experience of Persons Serving Alcohol______
c. What Measures are in Place to Prevent Service of Alcohol to Minors and/or Intoxicated Persons?______
______
Is a Liquor License Required for this Event? _ Yes _ No
a. Does Application have a Valid Liquor License? _ Yes _ No
Number of Bars or Areas at which Alcohol will be dispensed at this Event ______
a. Is Alcohol Consumption Confined to this (these) Areas? _ Yes _ No
b. If No, Please Describe______
c. Will there be an Open Bar? _ Yes _ No
d. Will Alcohol be Sold by the Drink? _ Yes _ No
e. Cost per Drink______
f. Is BYOB Permitted? _ Yes _ No
Will Food be Sold or Served with the Alcohol? _ Yes _ No
a. If Yes, Describe Food Available ______
Estimated Gross Receipts per Day Alcohol ______F_ o _o _ d ______
Total Estimated Gross Receipts for Event Alcohol ______F_ o _o _ d ______
Has the Applicant Received any Fines or Citations in the Last 5 Years? _ Yes _ No
a. If Yes, Please Describe ______
______
Has the Applicant had a Liquor Loss in the Last 5 Years? _ Yes _ No
a. If Yes, Please Describe ______
______
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Are there Cooking Facilities on the Premises? _ Yes _ No
If Yes, What type of Fire Protection is Present? ______
______
Is the Applicant Providing any Overnight Accommodations such as Camping? _ Yes _ No
If Yes, Please Describe______
______
Who is Responsible for Providing Security?______
If Other than the Applicant, is a Certificate of Insurance Provided? _ Yes _ No
If Other than the Applicant, is Applicant Named as Additional Insured? _ Yes _ No
Is the Security Provided Armed or Unarmed? ______
If the Event is being held on a Street or Other Public Place of Vehicular Access, what Protection is being Used between the
Street and the Sidewalk?______
Are Fireworks or Pyrotechnics to be Used? _ Yes _ No
If Yes, Please Describe______
______
Is the Applicant Signing any Hold Harmless Agreements? _ Yes _ No
If Yes, with Whom and What Responsibilities? ______
______
(Please Attach Samples of all Hold Harmless Agreements)
Is the Applicant being Held Harmless by Others? _ Yes _ No
If Yes, by Whom and What Responsibilities? ______
______
(Please Attach a Copy of the Agreement if Available)
Has this Event been held in the past by the Applicant? _ Yes _ No
If Yes, for how many Years?______
Have there been any losses? ____yes ____no If yes, please Describe any Losses over $5,000.00. ______
______
Has your Prior Insurance Ever Been Cancelled? _ Yes _ No
Has your Prior Insurance Ever Refused to Renew? _ Yes _ No
Do you have a Risk Management Plan? _ Yes _ No
Please Attach All Brochures of the Event and a Diagram of Location(s) to be Used.
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly provides false information in an application for insurance may be guilty of a crime and may be subject to civil fines and criminal penalties. I certify that the above information is true and coverage is not applicable until accepted by Rainprotection.net.
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Signature of Applicant Date
ph. (800)528-7975 / fax (631)586-3039