Please fill in all fields marked with a *

1. ---

2. Type of Event:

3. 	Beer Garden/Beer Tent		Fund Raiser		Individual Vendor Booth
   	Car Show		Motor Vehicle Race/Show		Picnic
   	Concert/Musical Performance		Competition or Show		Sporting Event/Tournament
   	Convention/Trade Show/Exhibit		Parade		Wedding/Wedding Reception
   	Festival		Party/Social Event		Other
   Other:

4. ---

5. First Name:*		Last Name:*
   Address:*		P.O. Box/Suite/Unit
   City:*		State:*	Select  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
   Zipcode:*

6. ---

7. Phone:*		Email:*
   Fax:		Website:

8. ---

9. Location Name of Event:

   Address of Event:

10. Will the event take place on the applicant's premises? Select   Yes No
11. Location is:

12. 	Private Residence		Liquor-Licensed Establishment		Indoors
    	Convention Center		Stadium		Outdoors
    	Arena		Fair Grounds		Other

13. Date of the Event (If one day event. end date should be the same as the start date. Quote will contemplate coverage for events continuing past 12am.):

14. From:

    To:

15. Desired Coverage Date(s):

16. From:

    To:

17. ---

18. If event date(s) differ from desired coverage date(s), explain:
     
19. Is set-up and take-down coverage needed for additional dates? Select   Yes No
20. If so, what are the dates and what will the exposure include? ( ie: any machinery )
     
21. Would you like to include a rain date? Select   Yes No
22. If so, when:

23. ---

24. Hours of Event:
25. From: To:
26. If hours vary by date, describe:
     
27. Full Schedule/Description and Purpose of Event:
     

28. ---

29. Is this part of a larger function? Select   Yes No
30. If Yes, describe:
     
31. Will there be any Entertainment? Select   Yes No
32. If Yes, describe (include name of performers and acts):
     
33. Is there an Admission Charge? Select   Yes No
34. If Yes, cost of admission per person? $

35. ---

36. ESTIMATED TOTAL ATTENDEES PER DAY: attendees
37. Average Age of Attendees:
38. If applicant is an individual exhibitor/vendor. what is the estimated attendees per day anticipated to visit their booth?
39. Attendance is:
40. Select   By Invitation Only Open to the Public
41. What is the Maximum Capacity of Facility holding Event: people

42. ---

43. Coverage Desired:
44. Select   Commercial General Liability & Liquor Liability Commercial General Liability Only Liquor Liability Only
45. Limits of Coverage Desired:

46. ---

47. History
48. Number of Years Event has been Previously Held: years
49. Actual Total Attendance for Prior Year's Event: attendees
50. Previous Carrier:
51. Policy Number:
52. Premium: $
53. Losses or Claims during the Past Five Years:
     

54. ---

55. Liquor Liability
56. Estimated Number Of Attendees Consuming Alcohol Daily: attendees
57. Is Applicant Sole Vendor of Alcohol at Event? Select   Yes No
58. If Not, List Number of Other Vendors Serving Alcohol: Vendors
59. Are all Participating Alcohol Vendors Required to Carry Minimum Liquor Liability for the Event? Select   Yes No
60. If Yes, What is the Minimum Requirement? $
61. Will Alcohol be Dispensed by a Professional Bartender? Select   Yes No
62. If No, Describe how and by whom Alcohol will be dispensed:
     
63. Describe training and/or experience of persons serving alcohol:
     
64. What measures are in place to prevent service of alcohol to minor and/or intoxicated persons?
     
65. If required, does applicant have a valid liquor license? Select   Yes No Not Required
66. Number of Bars or Areas at which Alcohol will be Dispensed at the Event
67. Is Alcohol Consumption Confined to this (these) Area(s)? Select   Yes No
68. If No, Describe:
     
69. Will there be an Open Bar? Select   Yes No
70. Will Alcohol be Sold by the Drink? Select   Yes No
71. If Yes, Cost Per Drink: $
72. Is BYOB ( Bring Your Own Bottle ) or Self-Service of alcohol permitted? Select   Yes No

73. ---

74. Will Food be Sold or Served Select   Yes No
75. If Yes, Describe Type of Food Available:
     
76. Estimated Gross Food Receipts per day:
77. Estimated Gross Alcohol Receipt per day:

78. ---

79. Commerical General Liability
80. Will event feature any of the following:
81. Rides, mechanical devices, rebounding devices Select   Yes No
    ( ie: moon bounce, rock climbing wall or trampolines )
82. If Yes, Explain which type:
     
83. If Yes, can a Certificate of Insurance be obtained for this exposure at the event? Select   Yes No
84. Will there be a Petting zoo or animal rides? Select   Yes No
85. If Yes, can a Certificate of Insurance be obtained for this exposure at the event? Select   Yes No
86. Will there be Firearms or Fireworks? Select   Yes No
87. Will there be Overnight Camping? Select   Yes No
88. Will there be Dunk Tanks? Select   Yes No
89. Are there any water hazards present?
90. Swimming Pool      Lake      Pond      Other:

91. ---

92. Will there be individual exhibitors, booths or vendors at the event? Select   Yes No
93. If Yes, are they required to carry their own insurance? Select   Yes No
94. What limit is required? $

95. ---

96. Describe SECURITY Measures:
97. Is Security provided by:
98. Select   Independent Contractors Employees of Applicant On-Duty Police
99. If Security is provided by independent Contractors, are they required to carry their own insurance? Select   Yes No

100. ---

101. If a MUSICAL EVENT:
102. Names of Performers:
      
103. What type of music?
104. Is this a Select   local national performer?
105. Is dancing permitted? Select   Yes No
106. Are performers required to carry their own insurance? Select   Yes No

107. ---

108. If EVENT is a PARADE, what is:
109. Number of Floats:
110. Number of Marching Units:
111. Length of Parade:
112. Will participants be throwing objects into the crowd? ( ie: candy, etc. ) Select   Yes No

113. ---

114. If ATHLETIC EVENT, give:
115. Number of Games
116. Type of Event: Select   Amateur Professional
117. Is Athletic Participants Coverage Desired? Select   Yes No

118. ---

119. If Event is a MOTOR VEHICLE RACE, RODEO, TRACTOR PULL OR TRUCK SHOW:
120. What type of barriers are in place to ensure spectator safety?
121. Are the barriers permanent? Select   Yes No
122. What is the distance bteween the event and the spectators?
123. Are spectators ever permitted in the pit or infield area? Select   Yes No

124. ---

125. Will there be temporary erected bleachers or grandstands? Select   Yes No

126. ---

127. * Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claims containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, may be committing a fraudulent insurance act, and may be subject to civil penalty or fine.
     * Not applicable in all States

128. ---

129. * By initialing here, I affirm that all information submitted in this application is true and correct to the best of my knowledge.

130. ---