Types of events your organize (check all that apply) Auto/RV/Motorcycle/Boat Shows Antique & Collectible shows Athletic Events/Exhibitions/Contests Auctions - describe: Baby or wedding showers Barbecues Beauty pagents and/or fashion shows Charity Events - describe: Church gatherings or baptisms Computer and/or electronic shows Concerts Festivals- describe:
Conventions/Trade shows/ Exhibitions - Corporate Trade Industry
Gun and/or Knife shows Health and/or Science fairs Home and/or Garden shows Open houses Meetings, Seminars or Speaking engagement - Corporate/Business Private Public Parties - Anniversary Birthday Dinner Holiday Office Theme Sports Event (e.g. Super Bowl) Other - describe:
Picnics - Corporate (employee only) Corporate (other) Private
Political gatherings, conventions or rallies Reunions Sightseeing trips Talent shows and/or Contests Theatrical and/or Movie Premiers Weddings and/or Wedding receptions
Number of events planned for the current year:
Number of events planned last year:
Do you sponser or promote any events?
Yes
No
Are you involved in any other operations or businesses? Or are you owned by, controlled by or affiliated with any other company?
Yes
No
Do you have any subsidiaries?
Yes
No
Within the past 5 years, have you changed your business name, acquired any business or merged or consolidated with another entity?
Yes
No
Do you own or lease (long term) a hall/banquet facility?
Yes
No
Do you or your employees provide any of the following services? - Automotive tours (Cars/Bus/Jeep/Other), Booking Agent, Construction of temporary structure, Babysitting, Fireworks, Horseback riding, Hot air balloon ride, Rope courses, Security operations: Bodyguard/Personal security, Bouncer/Crowd Control, Parking/Traffic control, Watchmen/Guard service, Shuttle/Taxi/Limo service, Valet service.
Yes
No
The exposures/activities listed above are not covered by this program. If any of these exposures/activities are provided by a third party, you should require evidence of liability coverage (certificate of insurance) from the entity/organization naming you as an additional insured.
Do you sign contracts on behalf of your client?
Yes
No
Is the contract executed between you and your clients and/or with 3rd parties?
Yes
No
Do you have any employees?
Yes
No
Are subcontractors/independent contracters used?
Yes
No
Do you rent furnish, or install any kind of equipment/devices/decorations?
Yes
No
Do you own or operate a retail store?
Yes
No
Do you plan or direct athletic event? (Walks/runs/golf tournaments/sport tournament)
Yes
No
Do you prepare or sell food as part of your services?
Yes
No
Do you plan or promote concerts of any genre?
Yes
No
Do you host events where you profit from the proceeds (ticket sales, merchandise, food, etc.)?
Yes
No
In the last five years have any of your customers:
Made allegations or complained about the performance, non-performance or timeliness of your products/services?
Yes
No
Refused to pay or stopped paying fees or dues due to alleged problems with your products/services?
Yes
No
In the past 5 years have you or any of the employees had their professional licenses or certifications suspended or revoked?
Yes
No
Are you aware of any actual or alleged fact, circumstance, situation, error or omission, which can reasonably be expected to result in a claim, suit, or proceeding being made against you?
Yes
No
What is the name of your current insurance carrier(s)?
Expiration date(s):
Is your current carrier non-renewing your coverage?
Yes
No
Please list and describe any liability or medical claims that have been paid under your insurance coverage for
the past three (3) years, including the amount paid. (If you have loss information, please provide a copy.)
Select an Option?
Choose
Option 1 - $1 million limit
Option 2 - $2 million limit
Annual Gross Receipts:
Rate:
Subtotal:
Program Premium :
You will receive a certificate showing evidence that coverage has been bound.
Please select an option to how you'd like to receive your certificate.
Through email
Through fax
Through Mail
Please make sure that you have completed everything to the best of your knowledge before going to the next page.