[U.S.] Sporting and Special Events (Spectator only) Application

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Request Date    02/05/2012 02:57:03 AM

Establishment/Insured information Name Address      City      State ALASKA ALABAMA ARKANSAS ARIZONA CALIFORNIA COLORADO CONNECTICUT DISTRICT OF COLUMBIA DELAWARE FLORIDA GEORGIA HAWAII IOWA IDAHO ILLINOIS INDIANA KANSAS KENTUCKY LOUISIANA MASSACHUSETTS MARYLAND MAINE MICHIGAN MINNESOTA MISSOURI MISSISSIPPI MONTANA NORTH CAROLINA NORTH DAKOTA NEBRASKA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEVADA NEW YORK OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VIRGINIA VERMONT WASHINGTON WISCONSIN WEST VIRGINIA WYOMING      Country      Zip code Phone number Fax number      E-mail Web Site      Form of Business Corporation Individual Joint Venture Limited Liability Company Limited Liability Partnership Partnership Other   Contact information Name Address information same as above Address      City      State/Province      Country      Zip/Postal Code Phone number Fax number      E-mail   Event's dates: From  To   Desired Coverage From  To   From what time?   To    If Hours vary by Date, describe   Additional quotes needed Weather Cancellation Non-appearance Prize General Information         Event Type Aircraft Events Anniversary Parties Antique Shows Art Festivals and Shows Auctions Auto Shows (Vehicles stationary) Award Presentations Baby Shower Ballet or other Classical Dance Shows Balloon Artists Banquets Baptism Bar Mitzvahs/Bar Mitzvahs Baseball Games and Events - Amateur Basketball Games and Events - Amateur Bazaars Beauty Pageants Belly Dancer Bicycle Rallies, Races and Events Bicycling Event - No Racing / Off-road Bingo Games Birthday Parties Block Parties, Street Closures and Street Fairs - Under 5,000 Spectators Block Parties/Street Closures/Street Fairs - over 5,000 in attendance Boat Shows (Dry Dock Only) Boat Shows - in water Body Building Contests Book Signing Bounce Houses Bowling Tournaments Boxing, Wrestling, Hockey and Football Games - Amateur Bridal Showers Bungee Jumping Business Meetings and Shows Camera Shows Card Games - Blackjack Card Games - Poker Card Shows Caricture Sketching Carnivals and School Events - No Mechanical Rides Carnivals with Amusement Devices Carolers Cartoonist Casino Nights Casino and Lounge Shows Chamber of Commerce Events Charity Benefits, Dances, Auctions, or Sales Cheerleading Events/Competitions - No Pyramids Chess Tournament Choirs Choirs - Outdoor Christmas Tree Lighting Church Services or Meetings Circuses Civic Club Meetings Classical Dance Shows Clowns - No Motorized Vehicles Comedians Comedy Shows Company or Corporate Retreats Computer Shows Concerts - 50's, 60's, 70's or 80's Music Concerts - Blues Music Concerts - Celtic Music Concerts - Chamber Music Concerts - Classical Music - Indoors Concerts - Classical Music - Outdoors Concerts - Country Music Concerts - Folk Music Concerts - Funk Music Concerts - Holiday Music Concerts - Instrumental Concerts - Motown Concerts - Not Otherwise Classified Concerts - Pop Cover Bands Concerts - Soul Music Concerts with Rap, Hip Hop, Heavy Metal, Ska, Punk or similar types of music Consumer Shows Conventions - Indoors Cornfield Mazes Country Festivals and Fairs - No Rides Country and Western Events - No Rodeos or Rides Craft Shows Cycling Events Dance Competitions Dance Recital Debutante Balls Debuts Dog, Cat, Bird & Other Domesticated Animal Shows/Events Drill Team Exhibitions Easter Egg Hunt Educational Exhibitions Electronics Conventions Evangelistic Meetings with Faith Healing or Similar Activities Exotic Animal Shows and Events Face Painters Fashion Shows Festival and Cultural Events - Outdoors Festival or Cultural Events - Indoors Film Production Film Screenings Film Showings Fireworks Fishing Events Flower and Garden Shows Fraternity Events Fund Raising Dinner Funeral Service Go Kart Races Golf Events - Non Professional Golf Tournament - Daytime Grad Night Graduations Gun and Knife Shows Gymnastic Competitions Halloween - Costume Contests Halloween - Haunted Houses Hang Gliding/Ski Diving Harvest Festivals - No farm Implements or Equipment Heads of State Events Holiday Events & Parties / Gift Exchanges Home Shows Hot Air Ballon Rides/Events Hypnotist Ice Skating Shows Impersonator - Celebrity or Holiday Character Impressionist Instructional Classes - Driver's Education, Flying or Health Jam and Jazz Concerts - Indoors Jam and Jazz Concerts - Outdoors Jewelery Maker Job Fairs - Indoors Job Fairs - Outdoors Jugglers - No Pyrotechnics Junior Athletic Games Karate Meets Lacrosse Games/Events Ladies Club Events Laser Tag Laser Tag - Indoors Lectures Livestock Shows Luge Luncheons Magic Show Magician Marathons (Walking and Running) - attendance 500 and under Marathons (Walking and Running) - attendance over 500 Mariachi Band Math Tournament Meetings - Indoors Meetings - Outdoors Menorah Lighting Mime Mobile Home Shows Mobile Home/RV Shows - Professionally Managed Mosh Pits Motorized Sporting Events Movie Release Party New Years Party (Open to public/not by invite only) New Years Party (Private/by invite only) Nightclub Shows Old Timer Events Overnight Camping and Retreats Pageants Paint Ball Parachuting Parades - Under 5,000 Spectators Parasailing Picnics - held at grounds without pools or lakes Play Readings Plays Poet Poetry Reading Political Rallies Pool/Billards Tournaments Professional Sports Professional and Amateur Association Meetings Promoters Proms Puppeteer Pyrotechnics Quinceanera RV Shows Raves Reality TV Shows Recitals Record Signing's in stores Renaissance Fairs/Festivals Reunions - Indoors Reunions - Outdoors Rodeo and Roping Events - Amateur Rodeo and Roping Events - Professional Roller Coasters/Sky Coasters Rugby Games/Events Rummage Sales - Other than for Charities Saddle Animals School Band Competitions or Events Scouting Jamborees - No Overnight Camping Seances Seminars Sidewalk Sales Skate Boarding Ski Event - Non-Professional Ski Events Sky Diving Slam Dancing Soap Box Derbies Soccer Games/Events Social Receptions - Indoors Social Receptions - Outdoors Softball Games/Events Sorority Events Speaking Engagements Sporting Events - Non-Professional and Indoors Sporting Events - Non-Professional and Outdoors Store Openings Story Teller Swap Meets/Flea Markets Swimming and Pool Facilities Symphony Concerts Talent Show - No Rap, hip hop, or heavy metal shows Tap Dancing Contest/Event Teleconferences Telethons Tennis Tournament Theatrical Stage Performances Tobogganing Tractor Pulls Trade Shows - Indoors Trade Shows - Outdoors Trampolines Triathlons Union Meetings Vacation Shows Ventriloquist Video Game Contests Volleyball Games - Amateur Voter Registration Wagon / Hayrides Walking / Hiking Tour Wall Climbing War Games/Re-enactments Water Events Water Slides Weddings and Wedding Receptions Wine Tasting Yodeler Other Name of Event Description of the event           Indicate the components of your event: Athletic/Sports   Yes No Musical/Entertainment   Yes No Parade   Yes No   Is there an admission charge?   Yes No      If Yes, cost of admission per person: Number of years event has been previously held      Total attendance for Prior Year's event      Venue Capacity Estimated Number Of Spectators / Attendance   Per Day Maximum Total Estimated Total Receipts $   I understand that only one event can be covered per policy   Yes No         Event Location   Will the event take place in the United States?   Yes No Address   Location is:   Indoors/Outdoors Indoors Outdoors   Location Type Liquor-Licensed Establishment Private Residence Convention Center Fair Grounds Stadium Arena Other   If Location Type is Other, describe: Commercial General Liability         Does the event include any of the following: Stunts, Pyrotechnics, Aircrafts, Animals, Hazardous Activities, Car Races, Precision Driving, Mechanical Devices?   Yes No   Will temporary grandstands/bleachers be used?   Yes No   Are Vendors, Attraction Owners, Performers or any other party(s) contracted for the event each required to carry their own insurance?   Yes No   Will the insured be selling products other than: CD's, tapes, brochures, posters, badges, clothing apparel, posters, stickers, badges, food and beverage?   Yes No      If Yes, please describe: Will the insured be selling more than $50,000 of products?   Yes No      If Yes, what is the estimated amount for total gross receipts from product sales? $ Are celebrities at the event?   Yes No      If Yes, which celebrities? Is the event overnight?   Yes No         Security Will security involve or include the use of any armed private security guards?   Yes No   Medical Will qualified medical personnel be in attendance?   Yes No         Coverage and Loss History   Have you (the applicant) ever filed for bankruptcy?   Yes No Have you ever had insurance cancelled, or non renewed for any reason?   Yes No If Yes, please explain         Was there any prior event with any losses of any kind declared by the insured and/or known by the broker?   Yes No   Indicate limits carried, corresponding premiums paid and total losses for the past 3 years (attach company loss history - verification if required). Type Limits ($) Premium ($) Total losses General liability                Participant legal liability                No Claims/Losses Loss Details Supply details for the two most significant losses which occurred over the past 3 years. Date Description of claim / accident, cause etc. Amount paid ($) (or reserve amount held)                                 Provide details for any other claims paid within the last 3 years:       Desired Coverage     Type Limits ($) General Liability (spectator only) $ 1,000,000.00 $ 2,000,000.00 $ 3,000,000.00 $ 4,000,000.00 $ 5,000,000.00 $ 6,000,000.00   Optional Coverages (Additional Premium Will Apply) Liquor Liability Coverage   Yes No      If Yes, please complete the Liquor Liability section below Waiver of Subrogation   Yes No Fire Legal Liability ($100,000.00 Included in basic plan) $ 100,000.00 $ 1,000,000.00 Non-Owned/Hired Auto Liability   Yes No      If Yes, please complete the Non-Owned/Hired Auto Liability section below Non-Owned/Hired Auto Liability Section         What is the estimated cost of hire? $   Describe fully all operations conducted by you which involve the use of automobiles (passenger carrying or otherwise)     Is a safety belt use policy in place for all passengers?   Yes No   What is the average number of days per week that each vehicle is operated 1 2 3 4 5 6 7   What is the average number of hours per day that each driver drives one or more of the vehicles 1 2 3 4 5 6 7 8 9 10 11 12   What percentage of driving is night driving? 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100   What evidence of auto insurance does your organization require from employees/volunteers using their personal autos? No verification takes place certificates of insurance copy of Auto ID Card copy of auto policy Other       If Other, explain:     Does the applicant have a formal written policy that addresses acceptable business use of personal vehicles?   Yes No   Does the applicant check MVR's (motor vehicle records) and apply disciplinary procedures for unacceptable MVR's?   Yes No   Is there a verification procedure for personal auto coverage and personal use reimbursement?   Yes No   Does the applicant have a driver safety program?   Yes No   Do employees and/or officers and partners lease or rent autos on the applicant's behalf?   Yes No         What is the number of autos leased (for the coverage period)         What is the average term of the lease (days)         What is the number of autos rented         What is the average term of rental (days)         How are the leased or rented vehicles used by the applicant?           Are only private passenger type autos leased or rented?   Yes No             If No, what type? (check all that apply)                 Transport Van    Bus                 Other       Explain:       Under whose name are the autos leased? Musical/Entertainment Event Section         Type of Music Please hold [ctrl] for multiple selection.   Alternative Blues Classical Country Electronica Heavy Metal Hip Hop House Industrial / Grunge Jazz Pop Rap Rock (hard) Rock (soft) Rhythm & Blues (R&B) Salsa Techno Other Liquor Liability Estimated number of attendees consuming alcohol daily      Is the applicant sole vendor of alcohol at this event?       Yes No      If No, please list other vendors selling alcohol :      Are all participating alcohol vendors required to carry minimum liquor liability for the event?       Yes No      If Yes, what is the minimum requirement :      Will the alcohol be dispensed by a professional bartender?       Yes No      If No, describe how and by whom alcohol will be dispensed:      Describe training and/or experience of person serving alcohol:       What measures are in place to prevent serving alcohol to minor and/or intoxicated persons?       Is a liquor license required for this event?       Yes No Does the applicant have a valid liquor license?       Yes No Number of bars/areas where alcohol will be dispensed at the event:      Is alcohol consumption confined to this (these) areas?       Yes No      If No, please describe:      Will there be an open bar?       Yes No Will alcohol be sold by the drink?       Yes No Cost per drink      Is BYOB (bring your own bottle) permitted?       Yes No Will food be sold or served?       Yes No      If Yes, describe the type of food available:      Please estimate gross receipts per day : Food     $ Alcohol $ Estimated Total Liquor Sales (gross receipts) $   Additional Named Insureds Do you require certificates of insurance for Additional Named Insureds?   Yes No Additionally Insured Certificate (1) : Name (to appear on certificate) Address City State/Province Country Zip/Postal code Contact Name (if available)           Phone Number           Fax Number           E-mail      Type of Business: Government/Municipalty Sponsor Sub-Contractor Beneficiary/Charity Venue/Facility   More Additional Insureds Additionally Insured Certificate (2) : Name (to appear on certificate) Address City State/Province Country Zip/Postal code Contact Name (if available)           Phone Number           Fax Number           E-mail      Type of Business: Government/Municipalty Sponsor Sub-Contractor Beneficiary/Charity Venue/Facility   More Additional Insureds Additionally Insured Certificate (3) : Name (to appear on certificate) Address City State/Province Country Zip/Postal code Contact Name (if available)           Phone Number           Fax Number           E-mail      Type of Business: Government/Municipalty Sponsor Sub-Contractor Beneficiary/Charity Venue/Facility   More Additional Insureds Additionally Insured Certificate (4) : Name (to appear on certificate) Address City State/Province Country Zip/Postal code Contact Name (if available)           Phone Number           Fax Number           E-mail      Type of Business: Government/Municipalty Sponsor Sub-Contractor Beneficiary/Charity Venue/Facility   More Additional Insureds Additionally Insured Certificate (5) : Name (to appear on certificate) Address City State/Province Country Zip/Postal code Contact Name (if available)           Phone Number           Fax Number           E-mail      Type of Business: Government/Municipalty Sponsor Sub-Contractor Beneficiary/Charity Venue/Facility   More Additional Insureds Additionally Insured Certificate (6) : Name (to appear on certificate) Address City State/Province Country Zip/Postal code Contact Name (if available)           Phone Number           Fax Number           E-mail      Type of Business: Government/Municipalty Sponsor Sub-Contractor Beneficiary/Charity Venue/Facility   More Additional Insureds Additionally Insured Certificate (7) : Name (to appear on certificate) Address City State/Province Country Zip/Postal code Contact Name (if available)           Phone Number           Fax Number           E-mail      Type of Business: Government/Municipalty Sponsor Sub-Contractor Beneficiary/Charity Venue/Facility   More Additional Insureds Additionally Insured Certificate (8) : Name (to appear on certificate) Address City State/Province Country Zip/Postal code Contact Name (if available)           Phone Number           Fax Number           E-mail      Type of Business: Government/Municipalty Sponsor Sub-Contractor Beneficiary/Charity Venue/Facility   More Additional Insureds Additionally Insured Certificate (9) : Name (to appear on certificate) Address City State/Province Country Zip/Postal code Contact Name (if available)           Phone Number           Fax Number           E-mail      Type of Business: Government/Municipalty Sponsor Sub-Contractor Beneficiary/Charity Venue/Facility   More Additional Insureds Additionally Insured Certificate (10) : Name (to appear on certificate) Address City State/Province Country Zip/Postal code Contact Name (if available)           Phone Number           Fax Number           E-mail      Type of Business: Government/Municipalty Sponsor Sub-Contractor Beneficiary/Charity Venue/Facility   If you require certificates for more Additional Insureds than specified above, please contact us

Fraud statement Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or a 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Warranty statement I hereby warant and confirm that the information included in this application, to the best of my knowledge, is true and correct, and further certify that I have read all of the questions and answers to this application. I understand this application is a requirement for coverage, a part of the contract and evidence of my acceptance of this insurance, and any falsification or misrepresentation will be deemed a breach of contract, voiding all insurance coverage. It is understood and agreed that the completion of this application shall not be binding either to the proposed insured or the company until accepted by the company or companies in writing.   I Agree