Event Insurance Questionnaire

SPECIAL EVENT PRODUCT

Please note, quotations take up to 48 business hours to complete. Also, coverage is not bound by this quote request. Thank you.

Type of Event A

Beer Garden/Tend

Concert/Musical/Theatre

Convention/Trade show/Exhibit

Competition or show

Type of Event B

Festival

Fundraiser

Individual Vendor Booth

Motor vehicle race/show

Type of Event C

Parade

Party/Social Event

Picnic

Health Fair / Convention

Type of Event D

Sporting / Athletic

Tournament

Wedding/Wedding Reception

Event - Other

You selected "other" please describe the event

Coverage Type and Limits

Coverage Type

Commercial General Liability ONLY

Liquor Liability ONLY

Commercial General Liability and Liquor Liability*

Limits of Coverage

What are the limits you are seeking?

We will evaluate your request and may have more questions,

Applicant Information

Applicant's Name(Required)

List only one legal and DBA name. Do not include "etal, " "Etc." or other similar wording in the name

Type of Event(Required)

Name of Event

Website

Applicant's Role in the event?(Required)

What role does the applicant play or what connection does the applicant have to this event?

Location Informaton

Address where the event will take place

Street Address Address Line 2 City State ZIP Code

Is the mailing address the same?

Yes

No

Mail Address

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email address of primary contact(Required)

Enter Email Confirm Email

Select form of Business

Form of Business

Please select

You selected "other" please explain

Number of Attendees(Required)

Will you be serving liquor or allowing others to serve liquor?(Required)

Yes

No

How many attendees do you anticipate will consume liquor?

Event Detail and Participants

1. Estimated Total attendees per day:

2. Estimated number attendees consuming Alcohol Daily

(if liquor liability coverage is desired)

Full schedule/description and purpose of event

(attach copy of brochure, website pages and flyer to this application or include details on all activities taking place) You are welcome to upload your brochure or email. Email to [email protected]

File - Upload up to 4 separate document if necessary

If you prefer to email the documents please email to [email protected] and be sure to include your business entity name.

Drop files here or

Accepted file types: pfd, jpg, jpeg, png, Max. file size: 20 MB, Max. files: 4.

Dates of Event

Note: If one day event, the end date should be the same as the start date. Quote will contemplate coverage for events continuing past 12 am.

From

What date will the event end?

To

Starting date

If event date(s) differs from desired coverage date(s) please explain

Is set-up and take-down coverage needed for additional dates?

Yes

No

Starting from what date?

To this Date

What will this exposure include?

Will there be any heavy machinery used such as bulldozers, backhoes, excavators, or any other types of industrial machinery (small forklifts and light machinery are acceptable)?

Yes

No

Would you like to include a rain date?

Yes

No

Which Date?

Would you like to include coverage for banners?

Yes

No

Do / Does the Banner hang above a major roadway or trail behind an airplane?

Yes

NO

Additional Interests, Insured, Certificates

Do you require any Additional Inureds?

Yes

No

Legal Name of Additional Insured

Describe the Additional Insureds interest

Name and Address of Additional Insured

Is there a landlord or property owner that required they be name on a Certificate of insurance?

Street Address City State ZIP Code

Special Endorsements

Would you like to include primary and non-contributory wording?

Yes

No

How manty contracts are needed for non-contributory wording?

Would you like to include waiver of subrogation?

Yes

No

How manty contracts are needed for waiver of subrogation?

History

Previous Insurance Carrier Name

Previous Policy Number

Insurance Claims

Concert / Musical / Theatre

Is this a concert/musical event?

Yes

No

Performs are

Local

National

Will pyrotechnics be featured?

Yes

No

Any special effects?

Yes

No

Describe special effects

Provide name of performer and describe type of music

Parade Event

Is this a Parade Event?

Yes

No

Describe parade route from start to finish

Has the Parade Event been approved by local authorities and will route be secured by police?

Yes

No

Please explain why it has not been approved by authorities.

Sporting / Athletic Events

Is this an Athletic Event?

Yes

No

Please describe this athletic event

Are athletes Professional or Amature?

Professional

Amature

Please list Professional Athletes

His this a Health Fair/Convention?

Yes

No

Will the Event feature any medical or health treatment?

Yes

No

Please acknowledge that you understand that coverage is NOT bound by submitting this Form.

I understand coverage is not bound

No I do not understand

SPECIAL EVENT PRODUCT

Coverage Type and Limits

Applicant Information

Location Informaton

Select form of Business

Event Detail and Participants

Dates of Event

Additional Interests, Insured, Certificates

Special Endorsements

History

Commercial General Liability

Water Hazards

Liquor Liability

Event Types

Concert / Musical / Theatre

Parade Event

Sporting / Athletic Events

Motor Vehicle Race

Car and Motor Vehicle Show

Health Fair / Convention

Questionnaire Guide