FacebookThis field is for validation purposes and should be left unchanged.Personal InformationApplicant Entity Type:(Required) Individual Partnership Coorporation LLC Joint Venture Applicant Name:(Required)Applicant Name:(Required) First Last Applicant Contact Name:(Required) First Last Date of Birth:(Required) MM slash DD slash YYYY Year Business Started:(Required)2026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900Gender:(Required) Male Female Other Marital Status:(Required) Single Married Divorced Widowed Home Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have a different Mailing Address?(Required) Yes No Mailing Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number:(Required)Email Address:(Required) Name of other individual(s) or group(s) taking part or in sponsoring this event: Add RemoveGeneral InformationType of Event:(Required) Party / Social Event Wedding / Wedding Event Fund Raiser Car Show Company Picnic Beer Garden / Beer Tent Competition or Shows Festival Concert/Musical Convention/Trade Show Parade Performance Festival Political Events Sporting Event / Tournament Individual Vendor Booth Other Other:(Required)Event Location:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Location is:(Required) Indoors Outdoors Both Is there another location the event will take place?(Required) Yes No Event Location 2:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Location is:(Required) Indoors Outdoors Both If the applicant is not taking part in or sponsoring the event, what is the relationship to the event?Event Start Date:(Required) MM slash DD slash YYYY Event End Date:(Required)(inclusive) MM slash DD slash YYYY Time of Event(Required)Will the event go past midnight?(Required) Yes No Will guests camp / sleep overnight?(Required) Yes No Desired Coverage Dates:(Required)(Please include set-up and clean-up days if applicable. If this is the same as event start and end dates, type "N/A")Maximum Daily Attendance(Required)Please enter a number greater than or equal to 0.Total Attendance(Required)(best estimate)Please enter a number greater than or equal to 0.Do participants sign waiver of liability agreements?(Required) Yes No Is there an admission fee?(Required) Yes No If yes, what’s the price of admission?(Required)Is admission:(Required) General Admission By Invitation Only (Private) Is Applicant an event coordinator?(Required) Yes No Will there be any heavy machinery used such as bulldozers, backhoes, excavators, or any other type of industrial machinery (small forklifts and light machinery are acceptable)?(Required) Yes No Will you have Vendors or Exhibitors at your event?(Required) Yes No Please acknowledge that Vendors will carry their own insurance, and provide you with Certificates of Insurance.(Required) I acknowledge Are there any water hazards present:(Required) Swimming Pool Lake Pond Other Other(Required)Animal ExposureWill there be exposure to animals at the event?(Required) Yes No Are there animal rides?(Required) Yes No If yes, list the type of animals:(Required)Are there any safety measures used?(Required) Yes No If yes, please describe:(Required)Is there a petting zoo?(Required) Yes No List the type of animals:(Required)Is the area supervised?(Required) Yes No Athletic EventIs this an athletic event?(Required) Yes No Number of participants:(Required)Age of Participants:(Required)Number of games:(Required)Is coverage desired for participants?(Required) Yes No Describe distance and protection between spectators and participants:(Required)Bicycle / Running EventIs this a bicycle / running event?(Required) Yes No Is the route surface free of hazards and clearly marked?(Required)Will all pedestrians and vehicular traffic be rerouted?(Required)EntertainmentWill live entertainment be provided?(Required) Yes No Is event a rave, rave dance, or rave party?(Required) Yes No Any celebrities to be present?(Required) Yes No If yes, provide names:(Required)Name of performer or group:(Required)Any special effects for the concert:(Required) Yes No If yes, describe:(Required)FireworksWill your event involve fireworks?(Required) Yes No Will there be a fireworks display?(Required) Yes No Will a licensed technician ignite the fireworks?(Required) Yes No If no, advise who will ignite them:(Required)Is the person igniting the fireworks insured for this operation?(Required) Yes No Will firemen be present?(Required) Yes No Will an ambulance be on hand?(Required) Yes No Will fireworks be sold?(Required) Yes No First AidWill first aid facilities be provided at the event?(Required) Yes No If yes, describe:(Required)Who will be charge of the facilities:(Required)Liquor and FoodIs liquor to be served by applicant?(Required) Yes No Served by Caterer If yes, describe:(Required)Is BYOB (Bring your own bottle) or self-service of alcohol permitted?(Required) Yes No If yes, describe:(Required)Is liquor required to be served by others?(Required) Yes No Is applicant required to have a valid liquor license for the event?(Required) Yes No Estimated number of attendees consuming alcohol daily:(Required)Food sold or served by applicant?(Required) Yes No Sold/Served by Caterer If you have a caterer, do they have existing insurance? Yes No Other If so, with what carrier?(Required)Parking FacilitiesWill you provide parking at the event?(Required) Yes No Operated by:(Required) Applicant Other If others, do they have their own insurance?(Required) Yes No Is parking area:(Required) Paved Dirt Other Rides / AttractionsWill inflatables be utilized?(Required) Yes No Will rides be provided?(Required) Yes No If yes, type of rides:(Required)Are the rides supervised at all times?(Required) Yes No Is the applicant property licensed to operate equipment?(Required) Yes No Does the vendor or subcontractor operate kiddie rides?(Required) Yes No Does the applicant have certificates of insurance from the ride or inflatable vendors?(Required) Yes No Security and Traffic ControlIs there a written emergency plan in the event of an accident?(Required) Yes No Does an independent security company provide a certificate of insurance?(Required) Yes No Who is responsible for crowd and traffic control?(Required)Are parking areas smooth with clearly marked parking areas and exit roads?(Required) Yes No Insurance QuestionsIs the venue requesting that the Applicant obtains insurance for this event?(Required) Yes No Please paste the insurance requirements requested by the venue so we may accurately assist you:(Required)Does the Applicant running this event have existing liability insurance?(Required) Yes No If so, what carrier, and aggregate limit ($)?(Required)Do you require the following coverages?(Required) Waiver of Subrogation Hired & Non-Owned Auto Abuse, molestation, exploitation coverage None of the above Will you need to list the location or any others as Additional Insured, or Certificate Holders?(Required) Additional Insureds Certificate Holders No Additional Insureds(Required)NameFull Address Add RemoveCertificate Holders(Required)NameFull Address Add RemoveAdditional InformationUse the space below to provide any other relevant information or special considerations that may affect your insurance policy. Δ
