Special Event Liability Insurance Application

Name of Applicant / Organization *

Applicant is: *

Individual Corporation Partnership Other

If Other, please explain (not required)

Applicant's interest in this event (not required)

Names of other individuals or groups taking part in or sponsoring this event (not required)

Name of the event venue (not required)

Location where the event will take place *

The location is: (not required)

If Other, describe the location (not required)

The event is being held: *

Indoor Outdoor Both indoor and outdoor

Type of event *

If Other, describe the event type (not required)

Full description of the event, schedule, and purpose *

Event website address (if any) (not required)

Is this part of a larger event? (not required)

Yes No

If yes, please describe the larger event (not required)

Event start date *

Event end date *

Hours of the event (e.g. 10:00 AM to 6:00 PM) (not required)

If multiple or recurring event dates, list them here (not required)

Coverage effective date (desired) *

Coverage expiration date (desired) (not required)

Is there an admission fee? *

Yes No

Price of admission (not required)

Estimated gross receipts (not required)

Admission is: (not required)

General Admission By invitation only

Total estimated attendees per day (not required)

Total estimated attendees for the entire event *

Maximum capacity of the location holding the event (not required)

Average age of attendees (not required)

What type of seating will be provided? (check all that apply) (not required)

Is the seating temporary or permanent? (not required)

Temporary Permanent Not applicable

If temporary, who is responsible for set up? (not required)

Water hazards present at the location (check all that apply) (not required)

If Other water hazard, describe (not required)

Has this event taken place before? *

Yes No

How many years has it been held? (not required)

What was the previous attendance? (not required)

Has the applicant had previous insurance for this or a similar event? (not required)

Yes No

Prior carrier (not required)

Expiring premium (not required)

Any losses in the past five years? (not required)

Yes No

If yes, describe the loss(es) (please also attach loss runs below) (not required)

Limits of liability requested *

Name of any Additional Insured (e.g. venue, city, sponsor) (not required)

Additional Insured's mailing address (not required)

Additional Insured's interest in this event (not required)

Will there be any live music? (not required)

Yes No

What type of music? (not required)

Name of entertainer / band (not required)

Any other type of entertainment? (not required)

Yes No

Describe the other entertainment (not required)

Any stage pyrotechnics? (not required)

Yes No

Stage pyrotechnics are: (not required)

Indoor Outdoor

Do you require all musicians/entertainers to provide a Certificate of Insurance? (not required)

Yes No

Describe any electrical or stage construction work performed by or for you (not required)

Sporting event: number of participants (not required)

Participants are: (not required)

Professional Amateur

Age of participants: (not required)

Under 18 Over 18 Both

Is coverage desired for the participants? (not required)

Yes No

Describe distance and protection between spectators and participants (not required)

Political event scope: (not required)

National State Local

Name and title of the political figure (not required)

Will there be carnival or amusement-type rides (including inflatables/bounce houses)? (not required)

Yes No

List all rides and inflatables (not required)

Do the ride operators carry their own insurance? (not required)

Yes No

Will there be any animals on display or petting zoos? (not required)

Yes No

Provide details and a list of the animals (not required)

Any saddle animals or carriage rides? (not required)

Yes No

Products sold or displayed by concessionaires (describe) (not required)

How many concessionaires will attend the event? (not required)

Will alcohol be served? *

Yes No

Alcohol will be served by: (not required)

Applicant Independent vendors

Will Liquor Liability coverage be obtained? (not required)

Yes No

Will there be any firework displays? *

Yes No

Name of the pyrotechnician (not required)

Is the pyrotechnician licensed? (not required)

Yes No

Name and address of the person or organization putting on the display (not required)

Will fire department and/or ambulance be on hand? (check all that apply) (not required)

Fire Department Ambulance

I understand the Fireworks Warranty (fireworks displayed at least 50 yards from spectators and parking; aimed away from spectators; a test display shot one hour prior; no wet fireworks used; all fireworks USA-sourced; area policed for debris; pyrotechnicians excluded from all liability coverage) will become part of any fireworks liability coverage issued. (not required)

I understand and agree

Describe the type of security and measures provided (not required)

Who provides security? (not required)

Employees of applicant Local or State Police Independent firm or contractor None

Security is: (not required)

Armed Unarmed

How would you like us to contact you? (not required)

How did you hear about us? (not required)

Type your full legal name to sign this application *

Your title (not required)

Special Event Liability Insurance Application

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📋 Special Event Liability Insurance Application Details

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