Special Event Insurance Application

SPECIAL EVENT INSURANCE APPLICATION

BROKER INFORMATION

Broker/Agency Name:
Contact Person:
Address:
City / State / Zip
Phone: / Fax:
E-mail Address: / Website:
GENERAL INFORMATION
1.Name of Insured (Applicant):
2.Address:
Street / City / State / Zip
3.Phone: / Fax:
4.Form of Business: Corporation Joint Venture Partnership LLC
Other (please describe):
5.Is the insured considered: For Profit Not-for-profitFederal ID #:
6.Date of Formation: / Chartered or Incorporated in What State?
7.Proposed Effective Date: / Website:
EVENT INFORMATION
8.Name of Event: / Type of Event:
9.Location of Event (Venue/Address):
10.Dates of Event: / Set-up/tear down dates:
11.Is this an annual event? Yes No
12.Event Manager: / Experience:
Event Risk Manager:
13.Will this event feature any of the following:
Rides, Mechanical Devices or Inflatables Petting Zoos or Animals
Fireworks (Pyrotechnics) Liquor
If any of these event features apply, please complete the appropriate section of this application.

1. Maximum daily attendance:

15.Are overnight accommodations or camping facilities provided for the event attendees or contracted for by the event organizer? Yes No
If yes, please provide a copy of the contract.
16.Will the event have vendors or exhibitors? Yes No
If yes, do you require that each vendor/exhibitor carries insurance and lists you as an additional insured?
Yes No
If no, do you require a vendor hold harmless/indemnification agreement (in your favor) be signed? Yes No
17.Are there musical/entertainment performers? Yes NoIf yes, please list below:
Performer/Entertainer Name / Type of Music/Program / Does the Performer/Entertainer have insurance?
Yes No
Yes No
Yes No
18. Please list all Additional Insureds and their relationship to the Named Insured:
Additional Insureds / Relationship to Named Insured
INSURANCE/UNDERWRITING INFORMATION
19.Responsibilities:
Please specify who has responsibility for the following event day operations:
Insured / Facility / Subcontractor/Other (please list)
Facility Maintenance
Maintenance of event area
Concessions - Non Alcohol
Concessions – Alcohol*
First Aid
Parking
Security*
Premises Defects
Transportation*
Fireworks*
Parade*
*If the insured handles this function, a separate application is required.
Please provide copies of all facility/venue agreements and/or subcontractor agreements.
20.Describe security protection:
21.Describe procedures for patron eviction and/or arrests:
22.Describe the precautions taken to prevent spectators from entering restricted areas. If an outdoor event, please describe fencing and other means to prohibit entry by non-ticket holders:
23.Type of medical facility/ambulance provided?
24.Is a stage used? Yes NoIf yes, please describe stage:
Type / Height / Width
Permanent
Temporary
25.If permanent, what systems or physical characteristics keep spectators off stage?
26.If temporary, who is responsible for set up of stage? Insured Other (please list):
27.Grandstand:TypeNo.Age in Years
Permanent
Temporary
28.If temporary bleachers used, do you require a Certificate of Insurance naming you as an additional insured from the owner of the bleachers? Yes No
If yes, please attach.
29.What percentage of attendance will be festival seating; i.e., non-reserved?
30.How long before scheduled performance time will you allow entry of spectators?
31.Are ushers used? Yes No
32.Describe number and types of gates and turnstiles:
33.What type of concessions are sold?
34.Will concessionaires provide you with Certificates on Insurance evidencing products liability with your organization as Additional Insured? Yes No
35.Who is responsible for pre-event inspection of the event premises?
36.Does the insured have custodial responsibility for minors? Yes No
If yes, is abuse coverage desired? Yes No
If yes, please complete Section A (below) of this application.
37.Will any other underlying coverage be provided for this event? Yes No
If yes, please describe:
38.How is this event being advertised?
39.Is facility in compliance with city, state, and township building, safety, and fire codes? Yes No
(NOTE: Non-compliance with codes will invalidate insurance)
40. / Coverage / Limit Requested / Limit Required
Per Occurrence: / $ / $ / Retention: / $
General Aggregate: / $ / $
Participant Legal Liability: / $ / $
Personal & Advertising Injury: / $ / $
Damage to Premises Rented to You: / $ / $
Products/Comp. Ops Liability: / $ / $

1. Attach a diagram of location. If event is held outdoors, describe fencing used to prohibit entry by non-ticket

holders, adjacent buildings, and landscape features:

1. If your organization is a member of a trade group or sanctioning body which hold insurance and/or risk

management seminars and/or meetings, indicate name of association:
43.Is this a sanctioned event? Yes No
If yes, name sanctioning organization:
44.Will you have remote parking? Yes No
45.What arrangements have been made for shuttle service?
PAST INSURANCE EXPERIENCE
46.Do you presently carry insurance of this type? Yes No
If yes, with which insurer?
47.Has any insurer ever canceled or refused coverage? Yes No
If yes, explain:
48.Insurance experience for Past Five Years First year for the event
Carrier
Year
Premium / $ / $ / $ / $ / $
Total Insured Claims (Paid & Reserved / $ / $ / $ / $ / $
49.Description of any individual claim or reserve in excess $10,000:
A.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 Coverage please skip this section and continue to the next section.)
50.Does the insured have custodial responsibility for minors? Yes No
If yes, is abuse coverage desired? Yes No
51. 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?
52.(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
53.(a)Do you verify employment-related references for employees? Yes No
(b)Do you verify employment-related references for volunteers? Yes No
54.(a)Do you conduct a personal interview for employees? Yes No
(b)Do you conduct a personal interview for volunteers? Yes No
55.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.
56.Do you have an Abuse / Molestation Policy with regard to sexual abuse? Yes No
If yes, please indicate how it is provided to your employees/volunteers.
57.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.
58.Describe how your organization supervises employees and volunteers having custody of children.
59.Describe specific policy regarding any overnight travel.
60.(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?
61.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?
62.Please indicate age range of minors in your care or under the supervision of your employees or volunteers at any time.
63.Please describe your current and/or planned operations that involve the custodial care of minors.

B.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.)

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

C.PYROTECHNICS

(Please complete this section if you need a quote for Pyrotechnics Coverage (scoreboard fireworks, etc.). If you do not need a quote for Pyrotechnics, pleaseskip this section and continue to the next section.)

90. Limit of liability requested: $1,000,000 Other:
91. Description of Events:
92. Location of Events:
Street / City / State / Zip
93. Dates of Events:
94.Who is the Authority having jurisdiction over the use of pyrotechnics at your facility?
Local Fire Department State Fire Marshal Other (please list):
95.What permit process must be followed prior to use of pyrotechnics at your facility:
96.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.
97.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)98. 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
99. Are events with pyrotechnics held: Indoors Outdoors
100.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)
101.Are the events in compliance with NFPA 1123 or 1126 (Code for Fireworks Display)? Yes No
102.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:
103.Will there be firefighting equipment on site during the event? Yes No
104.If no firefighting equipment on site, give distance to nearest fire station:
105.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)
106.Are the events in compliance with NFPA 1126 (Standard Code for the Use of Pyrotechnics before a Proximate Audience)? Yes No
107.Is the facility sprinklered? Yes No
108.What other form of fire fighting equipment is available at the facility?
109.Does the facility have an emergency evacuation plan? Yes No
If yes, how often is the staff drilled on emergency evacuation?
110.Number of accessible (not locked) emergency exits at the facility:
111.What steps are taken to inform patrons of the locations of all emergency exits?
112.Maximum capacity of the facility:
113.Has the fire marshal approved the use of pyrotechnics at the facility? Yes No
If yes, as of what date:

D.INFLATABLE COVERAGE

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

114. Provide detailed descriptions of the inflatable to be used (list name, description and, if possible, provide
brochures, pictures or internet address):
115. Who sets up the inflatable(s)? Rental Agency Insured Organization (you)
116. Where will the inflatable(s) be set up?
117. Is the inflatable(s) set up on flat ground? Yes No
118. Who inspects the inflatable to make sure that it is set-up correctly?
Rental Agency Insured Organization
119. Hours of operation:
120. How many attendants at each ride?
121. Are all attendants over the age of 18? Yes No
If no, please describe:
122. Describe attendant’s responsibilities:
123. Who is the manufacturer(s) of the inflatable(s)? Get from rental company if necessary:
124. How often is the inflatable(s) checked and inspected? Get from rental company:
125. Does the rental company keep a maintenance or inspection log? Yes No
126. Explain the emergency plan in case of unplanned deflation:
127. Describe the plan for weather emergencies (e.g. rain and/or high winds):
Explain method of communication from inflatable site should an emergency arise:
128. How is weight/age limitation enforced?
129. Are riders of similar size and ability grouped together on inflatable bounces? Yes No
130. With regard to inflatable rides that allow riders to participate one at a time, what is the guideline for letting the next
participant go (e.g. large inflatable slides – one at a time participation):
131. Will the inflatable have permanently attached warning labels and safety instructions? Yes No
132. Does inflatable provider carry $1m in GL insurance with an “A” rated carrier? Yes No
133.Will the provider list your organization as an additional insured? Yes No
134. Will your employees/volunteers receive formal training on the safe operation of the ride? Yes No
135. Is there an emergency plan in place and included as part of your operator training? Yes No
136. Is the ride picked up by the rental agency immediately after the rental event ends? Yes No
137. Will a liability release waiver or rental contract be signed? Yes No
If yes, please provide a copy.
138. First aid available at the event? Yes No
139. Injury/lost property disclaimer sign used at the inflatable site. Yes No
If yes, please provide verbiage or photo of sign:
140. Will the power be provided by a generator on site? Yes No
141. Has your organization had any incidents/claims relating to the use of inflatable? Yes No
If yes, please explain:

IMPORTANT INFORMATION REGARDING INFLATABLES – PLEASE NOTE:

By providing this information regarding inflatable and signing this application for insurance coverage, I agree to:

Follow the manufacturer recommendations regarding the proper site layout, inflation procedures, ropes, tethers, tie-downs, anchors, and use temperature range, maximum number of riders, size of riders, electrical codes, daily operation, daily inspection, washing, repair, drying, storage, supervision requirements and warning signage.

Not to inflate or allow to inflate rides in high winds or rain

Use rides in high winds or rain

Have ride attendants trained on evacuation procedures.