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Basic Information for Quotation
Special Events Application
Short Term Film Productions
Equipment Floater
Vendors and Exhibitors
Declared Production
Declared Event
Motion Picture/TV Production

Basic Information for Quotation

General Information

DBA/Name of Business:

Entity Type:

Individual

Partnership

Corporation

Limited Corp

Other

No data entered

Name(s) of owners:

% of ownership of each:

Year business started:

Primary Address (No P.O. Box):

Street Address Address Line 2 City State ZIP Code

Mailing Address

Mailing Address (if different than above)

Mailing Address (P.O. Box - OK):

Street Address Address Line 2 City State ZIP Code

Contact Person:

Phone:

Fax:

Email:

Website:

Describe type of business:

Describe your business operations:

Liability Insurance

Prior insurance co.:

Effective Date:

MM slash DD slash YYYY

Liability Limit:

Estimated annual sales/revenue:

Estimated annual payroll:

Estimated subcontractor costs:

Are there any additional insureds? (landlord, etc)

Yes

Name of Additional Insured:

Additional Insurance Address:

Street Address Address Line 2 City State ZIP Code

Property Insurance

*Additional locations send in an email

Prior Insurance Co.:

Effective Date:

MM slash DD slash YYYY

Location Address:

Street Address Address Line 2 City State ZIP Code

Are you a/an:

Owner

Tenant

Year Built:

Square Footage:

Construction Type:

What % of building is occupied by your business:

Number of Stories:

Sprinklered:

Yes

Alarmed:

Yes

Name of Alarm Co.:

Building Improvements Made:

Wiring

Roofing

Plumbing

Heating/Air

Completed what year:

Describe other business types in the building:

Need Building Insurance?

Yes

Building Limit:

Business Personal Property Limit:

Computers/Media Limit:

Mobile Equipment Limit:

Workers Comp Insurance

Prior Insurance Co.:

Effective Date:

MM slash DD slash YYYY

Number of employees:

Estimated annual payroll:

Estimated annual sub-contractor cost:

Claims

Any claims in the past 5 years?

Yes

Please describe:

Additional Comments

Additional Comments:

FRAUD STATEMENT

Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance 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 the person to criminal and (NY: substantial) civil penalties. (Not applicable in CO, HI, NE, OH, OK, OR, VT). In DC, LA, ME, TN and VA, insurance benefits may also be denied.

CAPTCHA

Special Events Application

General Information

DBA/Name of Business:

Entity Type:

Individual

Partnership

Corporation

Limited Corp

Other

No data entered

Physical Address (No P.O. Box)

Street Address Address Line 2 City State ZIP Code

Mailing Address

Mailing Address (if different than above)

Mailing Address (P.O. Box - OK)

Street Address Address Line 2 City State ZIP Code

Contact Person:

Phone:

Fax:

Email:

Website:

How much experience do you have at operating this type of event?

Qualification Questions

Any: Stunts, Pyrotechnics, Aircraft, Hazardous Activities, Car Races, Precision Driving, Mechanical Devices, Film Production, Rap/Hip-Hop, Rock/Metal, Rides, Water Activities

Yes

The event will take place in the United States:

Yes

Any armed private security guards?

Yes

Any Prior event with any losses of any kind?

Yes

Any bounce houses or inflatables?

Yes

Certificates of insurance are required

Will your event occur in a bar or nightclub?

Yes

(Concert): Is there assigned seating?

Yes

Will there be temporary structures installed/built for your event?:

Yes

Event Details

Effective Date:

MM slash DD slash YYYY

Expiration Date:

MM slash DD slash YYYY

Time:

If event is past midnight - add extra day - as insurance expires at 12:01am

Hours

Minutes

AM/PM

Load In Date:

MM slash DD slash YYYY

Load Out Date:

MM slash DD slash YYYY

Do you want these rates included in your quote?

Yes

Not Applicable

Average Daily Spectators/Guests:

*Important for rating purposes

Average Daily Participants: (volunteers, ushers, ticket takers, athletes, performers, etc.)

*Important for rating purposes

Please describe participants and how many of each:

Type of Event:

Is there overnight stays/camping?

Yes

Event Name:

Budget (Cost of Event):

Brief Description of Event:

Event Website:

Venue Name:

Physical Address (No P.O. Box)

Street Address Address Line 2 City State ZIP Code

Location Information:

Indoor

Outdoor

Both Indoor/Outdoor

Any Celebrities at Event?

Yes

List Celebrities (if any) at Event:

Music / Bands / Performers / Entertainment

Type of Performance/Entertainment:

Solo Artist

Live Music

Comedian

Name of Performer/Entertainment:

Type of Music:

Music Decade:

Artist/Band Name:

Do you require an additional insured certificate from the entertainers naming YOU as an additional insured on their insurance policy?

If not, there may be an additional premium charge of $135 (minimum) depending on the insurance market used to insure the band/performer with their own policy.

Yes

Not Applicable

Additional Insured

Do you hire any subcontractors for the insured event(s), (ie: caterers, bands/entertainment, lighting, sound, staging, decorations, security, etc.)?

Yes

Please describe:

Do you require all subcontractors to have their own insurance and provide you with a Certificate of Insurance (COI) naming you as an Additional Insured (AI)?

Yes

How many security personnel will be present? (If none, enter: 0)

Please note that for higher risk events it may be required to have 1 security person per 100 attendees.

Do you hire security?

Yes

Name of Security Company:

Number of On-Duty Police Officers:

If none, enter: 0

Number of Off-Duty Police Officers:

If none, enter: 0

Number of Private Armed Security:

If none, enter: 0

Number of Uniformed (unarmed) Security:

If none, enter: 0

T-shirt Security:

If none, enter: 0

Do you have metal detectors at all entrances and exits that attendees and performers must pass through?

This will be required for higher risk events.

Yes

Coverage Options

GENERAL LIABILITY: Blanket Additional Insureds & Certificates, including City Certs: Automatically Included

Occurrence / Aggregate Limit:

1,000,000 / $1,000,000

1,000,000 / $2,000,000

2,000,000 / $2,000,000

3,000,000 / $3,000,000

4,000,000 / $4,000,000

5,000,000 / $5,000,000

Waiver of Subrogation:

*Only if required by contract

Include

Exclude

What is the name of the entity requesting the waiver of subrogation?

What is their involvement in the event?

Additional Coverages

Rented Equipment Limit:

$5,000 minimum - $2,000,000 maximum

Dates rented equipment will be delivered:

MM slash DD slash YYYY

Dates rented equipment will be returned:

MM slash DD slash YYYY

Will rented portable equipment (i.e. lighting, sound, video, portable toilets, generators, forklifts, etc.)

Yes

Will rented Furniture be used (i.e. dining tables, any kind of chairs, sofas, coffee tables, end tables, etc.)

Yes

Will rented Fixtures be used (i.e. awnings, tents, etc.)

Yes

Will rented Growing Plants be used (i.e. ficus trees /bushes, other types of potted plants be used as barriers or decoration)

Yes

Will the property be stored overnight?

Yes

Will you be responsible for transporting the property?

Yes

Please provide details on how it will be stored:

Please describe how it is being transported:

Who is transporting the property?

Self

Rental House

Other

Name of company transporting the property:

Is the company transporting the property naming you as an Additional Insured on their insurance policy?

Yes

Not Applicable

Will the property stay in your possession at all times prior to returning to rental company? Will it be secure?

Yes

Please explain:

Third Party Property Damage:

*Minimum premium $100. Important Coverage for the Venue

Liquor Liability:

*$1,000,000 Limit

Include

Exclude

Will alcohol be served by a Licensed bartender?

Yes

Who will be serving the alcohol?

Describe the training and/or experience of persons serving alcohol:

Average age of attendees:

If none, enter: 0

What measures are in place to prevent the service of alcohol to minors and/or intoxicated persons?

Wrist bands, stamped wrist, tickets with I.D. check, none, etc.

Does the Applicant have a valid Liquor License?

Yes

Who has the liquor license?

Please identify by name and if a caterer, restaurant, sponsor, event planner, none, etc.

Please describe what kind of alcohol will be served:

Beer

Wine

Cocktails

Other

List other alcohol:

Will there be an open bar?

Yes

Not Applicable

Will alcohol be sold by the drink?

Yes

Not Applicable

Is BYOB allowed?

"Bring Your Own Bottle"

Yes

Not Applicable

Estimated alcohol gross receipts?

If none, enter: 0

Hired & Non-Owned Auto Liability

$1,000,000. Minimum premium $500

Include

Exclude

Are you required by contract to acquire Hired/Non-Owned Auto and you NOT being loaned, rented or leased any vehicles?

Yes

Please provide a copy of the contract:

Max. file size: 128 MB.

Amount being charged to rent or lease the vehicle(s)?

Are all drivers at least 25 years of age?

Yes

Not Applicable

Do all drivers have a valid United States drivers license?

Yes

Not Applicable

Do any of the hired vehicles seat more than 12 people?

Yes

Not Applicable

What will the vehicles be used for?

Event Cancellation, Participants Medical, Spectators Medical

Event Cancellation

Minimum premium $250

Include

Exclude

Participants Medical

Minimum premium $200

Include

Exclude

Spectators Medical

Minimum premium $200

Include

Exclude

Vendors Coverage
Only if you want your coverage extended to the vendors

Number of Exhibitors

No sales

Concessionaires

Non-food sales

Concessionaires

Food sales

Performers and Attractions:

Do you require all Vendors/Exhibitors to have their own liability insurance and provide you with a certificate of insurance naming you as an additional insured?

Yes

Not Applicable

Workers Compensation

Include

Exclude

Waiver of Subrogation

*Only if required by contract

Include

Exclude

What is the name of the entity requesting the waiver of subrogation?

What is their involvement in the event?

Payroll Company Name (if any):

Payroll

Classification

# Full Time:

# Part Time:

Payroll (W-2, 1099, Other)

Classification

# Full Time:

# Part Time:

Payroll (W-2, 1099, Other)

Classification

# Full Time:

# Part Time:

Payroll (W-2, 1099, Other)

Listing of All Officers
*To exclude from workers comp

First Name

Last Name

Title/Position

First Name

Last Name

Title/Position

First Name

Last Name

Title/Position

Additional Comments

FRAUD STATEMENT

CAPTCHA

Short Term Film Productions

Contact Information

Name Insured:

Entity Type:

Individual

LLC

LLP

Corporation

Non-Profit

Trust

Physical Address (No P.O. Box)

Street Address Address Line 2 City State ZIP Code

Mailing Address

Mailing Address (if different than above)

Mailing Address (P.O. Box - OK)

Street Address Address Line 2 City State ZIP Code

Contact Person:

Phone:

Fax:

Email:

Website:

Year Business Established:

Qualification Questions

Will the production include any Hard-Core or Soft-Core pornography?

Yes

Will the production include any live gangster rap music?

Yes

Will any production activities take place outside of the U.S. and Canada?

Yes

Any employees supplied to or from an employee leasing operation (i.e. PEO)?

Yes

Confirm your understanding that if coverage is provided, only one production will be covered by the policy(s) issued:

Yes

Any unprotected or open heights above 15 feet?

Yes

Insurance History

Losses

Any losses in the past 3 years?

Yes

Policy Type / Line of Business

Date of Loss

MM slash DD slash YYYY

Description

Amount of Loss

Policy Type / Line of Business

Date of Loss

MM slash DD slash YYYY

Description

Amount of Loss

Prior Coverage

Any prior insurance?

Yes

Policy Type / Carrier

Policy #

Expiration Date

MM slash DD slash YYYY

Premium

Policy Type / Carrier

Policy #

Expiration Date

MM slash DD slash YYYY

Premium

Cancelled or Declined Insurance (not applicable in MO)

Any insurance declined or cancelled in the past 3 years?

Yes

Provide details:

Production Details

Working Title:

Type of Production:

Gross Production Cost:

Number of Episodes (optional)

Production Start Date:

MM slash DD slash YYYY

Production End Date:

MM slash DD slash YYYY

Shooting Locations(s) - Cities & States:

Shooting Locations(s)

City State

Shooting Locations(s)

City State

Synopsis:

For Music Video Only

Type of Music:

Music Decade:

Artist Name:

Production Personnel

First & Last Name

Personnel Role

Drivers License #

State of Issue

Country of Residence

First & Last Name

Personnel Role

Drivers License #

State of Issue

Country of Residence

First & Last Name

Personnel Role

Drivers License #

State of Issue

Country of Residence

Stunts and/or Hazardous Activities

Will the production include any stunts, pyrotechnics, aircraft, boats, animals, race tracks, race courses, helicopters, motorbikes, snowmobiles, ATVs, blanks, squibs, guns or other hazardous activities?

Yes

Stunts

Type of Stunts:

Aerial Scenes

Water Scenes

Falls

Precision Diving

Fight Scenes

Weapons

Animals

Recreational Vehicles

Detailed Description of Stunt:

Date(s) of Stunt:

Stunt Coordinators/Professionals, if any:

Licensed?

Yes

Permits

Are permits required?

Yes

Have they been obtained?

Yes

Any cast members involved/in close proximity:

Yes

Describe precautions taken for the safety of the public, participants and property:

If vehicle(s) involved

# of vehicles:

Maximum speed

Any collisions or explosions?

Yes

Animal Coverage

Type of Animal and breed if applicable:

Value of Animal:

Where will animal be housed during/after filming:

Who is responsible during transport:

Days of filming:

Number of scenes:

Any replacements for the animal and can they substitute at all times:

Yes

Required Notes and Attachments

Detailed synopsis of stunt:

Certain stunts/hazardous activities are ineligible. Certain coverages (such as workers compensation) may not be available for productions that include stunts/hazardous activities.

Attach resume of stunt coordinator/pyrotechnician, permits:

Max. file size: 128 MB.

Coverage Options

General Liability

Occurrence / Aggregate Limit:

Blanket Additional Insured/Certificate of Insurance:

City Certificates:

Include

Exclude

Waiver of Subrogation

Include

Exclude

Inland Marine

Rented Equipment (Camera, Lighting, Sound, etc.)

*Values over 600k require a formal resume.

Rented Props, Sets, Wardrobe:

Owned Equipment, Propet Sets, Wardrobe:

Negative Film, Videotape & Digitalized Image:

Third Party Property Damage:

Extra Expense:

Office Contents:

Automobile

Hired & Non-Owned Auto Liability:

Waiver of Subrogation:

Include

Exclude

Hired & Non-Owned Auto Physical Damage:

*Per vehicle/aggregate limit

Workers Compensation
(available in CA, NY, FL, TX, NC, TN, NV, IL, CO)

Workers Comp required by SAG?

Yes

Not Applicable

Waiver of Subrogation?

Include

Exclude

Number of Shoot Days:

Certificate Holder Name

First Last

Certificate Holder Address

Street Address Address Line 2 City State ZIP Code

Payroll Company Name (if any):

Payroll

Classification:

# Full Time:

# Part Time:

Payroll (W-2, 1099, Other)

Classification:

# Full Time:

# Part Time:

Payroll (W-2, 1099, Other)

Classification:

# Full Time:

# Part Time:

Payroll (W-2, 1099, Other)

Classification:

# Full Time:

# Part Time:

Payroll (W-2, 1099, Other)

Listing of All Officers
*To exclude from workers comp

Title

First & Last Name

SSN

Date of Birth

MM slash DD slash YYYY

Title

First & Last Name

SSN

Date of Birth

MM slash DD slash YYYY

Title

First & Last Name

SSN

Date of Birth

MM slash DD slash YYYY

Title

First & Last Name

SSN

Date of Birth

MM slash DD slash YYYY

Additional Comments

FRAUD STATEMENT

CAPTCHA

Equipment Floater

Contact Information

Name Insured:

Entity Type:

Individual

LLC

LLP

Corporation

Non-Profit

Trust

Physical Address (No P.O. Box)

Street Address Address Line 2 City State ZIP Code

Mailing Address

Mailing Address (if different than above)

Mailing Address (P.O. Box - OK)

Street Address Address Line 2 City State ZIP Code

Contact Person:

Phone:

Fax:

Email:

Website:

Year Business Established:

Description of Operations:

Qualification Questions

Is the applicant in the business of renting equipment to others?

Yes

Insurance History

Losses

Any losses in the past 3 years?

Yes

Policy Type / Line of Business

Date of Loss

MM slash DD slash YYYY

Description

Amount of Loss

Policy Type / Line of Business

Date of Loss

MM slash DD slash YYYY

Description

Amount of Loss

Prior Coverage

Any prior insurance?

Yes

Policy Type / Carrier

Policy #

Expiration Date

MM slash DD slash YYYY

Premium

Policy Type / Carrier

Policy #

Expiration Date

MM slash DD slash YYYY

Premium

Cancelled or Declined Insurance (not applicable in MO)

Any insurance declined or cancelled in the past 3 years?

Yes

Provide details:

Coverages - Inland Marine

Owned Equipment

Coverage

Limit

Deductible

Coverage

Limit

Deductible

Coverage

Limit

Deductible

Coverage

Limit

Deductible

Coverage

Limit

Deductible

Coverage

Limit

Deductible

Coverage

Limit

Deductible

Coverage

Limit

Deductible

Rented Equipment

Coverage

Limit

Deductible

Coverage

Limit

Deductible

Coverage

Limit

Deductible

Coverage

Limit

Deductible

Coverage

Limit

Deductible

Coverage

Limit

Deductible

Coverage

Limit

Deductible

Coverage

Limit

Deductible

Coverage

Limit

Deductible

Coverage

Limit

Deductible

Coverage

Limit

Deductible

Coverage

Limit

Deductible

Coverage

Limit

Deductible

Coverage

Limit

Deductible

Coverage

Limit

Deductible

Coverage

Limit

Deductible

Worldwide Coverage Territory

Include

Exclude

Waiver of Subrogation

Include

Exclude

Coverage Extension Endorsement

Include

Exclude

* (Valuable Papers 2500, Signs 10000, Outdoor Property 5000 Per Item 25000 total, Electronic Media And Records 5000, Debris Removal 50000, Employee Dishonesty 5000, Fire Department Service Charges 25000, Fire Equipment Recharge 10000, Polutant Clean Up And Removal 15000, Sewer Backup 25000, Temporary Location 25000, Accounts Receivable 25000, Money & Securities 5000)

Additional Comments

FRAUD STATEMENT

CAPTCHA

Vendors and Exhibitors

Contact Information

Name of Company / Organization:

Entity Type:

Individual

LLC

LLP

Corporation

Non-Profit

Trust

Physical Address (No P.O. Box)

Street Address Address Line 2 City State ZIP Code

Mailing Address

Mailing Address (if different than above)

Mailing Address (P.O. Box - OK)

Street Address Address Line 2 City State ZIP Code

Contact Person:

Phone:

Fax:

Email:

Qualification Questions

Any: Stunts, Pyrotechnics, Hazardous Activities, Mechanical Devices, Animals Rides, Rap/Hip-Hop/rock/metal music performances, massage machines:

Yes

Exhibitor will be stationed behind their booth or in a designated area through-out the event?

Yes

The event will take place in the United States?

Yes

Are you responsible for any type of security or maintenance personnel?

Yes

Any Prior Losses related to Event's Exhibits?

Yes

Event Details

Vendor or Exhibitor Name:

Vendor or Exhibitor Description:

Budget (Exhibitor Cost):

Description of Exhibitor's Activities:

Venue Information

Venue Name Address City State ZIP Code

Event Organizer Information

Events Organizer's Name Address City State ZIP Code

Location Information:

Indoor

Outdoor

Both Indoor/Outdoor

Coverage Options

Attendance

Coverages

General Liability ($1,000,000)

Blanket Additional Insureds & Certificates, including City Certs:

Waiver of Subrogation:

Include

Exclude

Third Party Property Damage:

None

$25,000

What type of Exhibitor are you

Type of Exhibitor:

Exhibitor (no sales)

Concessionaire (food sales)

Concessionaire (non food sales)

What type of product are you selling?

Coverage Dates of the Event

Date

Additional Comments

FRAUD STATEMENT

CAPTCHA

Declared Production

Contact Information

Name of Company / Organization:

Entity Type:

Individual

LLC

LLP

Corporation

Non-Profit

Trust

Physical Address (No P.O. Box)

Street Address Address Line 2 City State ZIP Code

Mailing Address

Mailing Address (if different than above)

Mailing Address (P.O. Box - OK)

Street Address Address Line 2 City State ZIP Code

Contact Person:

Phone:

Fax:

Email:

Qualification Questions

Any: Stunts, Pyrotechnics, Aircrafts, Boats, Animals, Race Tracks, Race Courses, Helicopters, Motorbikes, Snowmobiles, Blanks, Squibs, Guns, Rap Music?

Yes

Check each exposure:

Stunts

Pyrotechnics

Aircrafts

Boats