Annual Theatrical/Musical Production Liability Questionnaire
LIABILITY COVERAGE TO INCLUDE PARTICIPANT THIRD PARTY LIABILITY CLAIMS
PLEASE PRINT CLEARLY OR TYPE OUT ANSWERS
CONTACT NAME: ______Contact person is: Owner Promoter Agent Other ______
PHONE #: ______FAX #: ______E-MAIL: ______
INSURED ENTITY NAME:______
Insured is: CorporationPartnershipJoint Venture Other
ADDRESS: ______
______
NAME OF EVENT:______
EVENT LOCATION(S) ______
FACILITY NAME /ADDRESS
______CITY STATE ZIP
DESCRIPTION OF EVENT:______
______
DESIRED EFFECTIVE DATE:______
DESIRED EXPIRATION DATE:______
Number of UNIQUE STAFF/VOLUNTEERS PER CALENDAR YEAR______
(how many different “heads” over the course of one year?
This includes Actors, Directors, Ushers, Stagehands, etc)
Please fill out the following in regards to any other upcoming planned productions in the next year.
event Date(S): ______
EVENT DESCRIPTION: ______
VENUE OR FACILITY: ______
event Date(S): ______
EVENT DESCRIPTION: ______
VENUE OR FACILITY: ______
event Date(S): ______
EVENT DESCRIPTION: ______
VENUE OR FACILITY: ______
Does your organization currently utilize a waiver of liability form? Yes No
If you do not know the answer to the question above, select NO
Accident medical coverage is required in order to place participant liability coverage
VOLUNTEER Accident coverages available:
Eligibility:All Participants & Staff of the Policyholder.
Benefits
Up to $25,000.00Maximum Medical Benefit per Claim
Up to $5,000.00Accidental Death/Dismemberment Benefit per Claim
$0, $25, or $50 Deductible per Claim
Primary or Excess Coverage
Dental Benefit: Included in Maximum Medical Benefit
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WILL YOUR ORGANIZATION BE SERVING OR SELLING ALCOHOL? ______
If yes, please describe: ______
HAS THIS EVENT BEEN HELD IN THE PAST BY THIS APPLICANT?______
IF SO, WERE THERE ANY LOSSES OR CLAIMS? ______
Please Describe ______
WAS THERE A PREVIOUS INSURANCE CARRIER? YES NO
If So, Who?______Approximate Premium Paid: ______
ADDITIONAL INSURED(S) (USUALLY THE FACILITY HOSTING THE EVENT)
Event #1 Facility nameStreet address
City StateZip
______
Contact NamePhone # Fax #E-mail address
Event #2 Facility nameStreet address
City StateZip
______
Contact NamePhone # Fax #E-mail address
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 is a crime and subjects such person to criminal and civil penalties, as well as the withdrawal of such insurance and/or the denial of any coverages and/or claims.
Signed by applicant: ______Date ______
Printed name of applicant ______
BROKER CONTACT (IF APPLICABLE)
AGENCY NAME______
REPRESENTATIVE______
PHONE # ______EMAIL ______Date ______