Applicant Information
Who is applying for this insurance? *
What is the applicant’s address? *
What is the applicant’s website address? (Enter http:// or https:// first)
What is the applicant’s email address? *
What is the first name of the contact person for billing matters? *
What is the last name of the contact person for billing matters? *
What is their phone number? *
Is this the same person in charge of loss control?
Who is the contact person for loss control?
Enter the phone number for the loss control contact person?
What effective date is the applicant requesting for this event insurance?
MM slash DD slash YYYY
What is the gross revenue for this event?
What type of entity is the applicant?
How many years has the applicant been in business?
How many years experience does the owner of this entity have in this type of business?
Has the applicant had any claims filed against them in the last four years? *
Please provide the following details for all claims in the past 4 years. *
Event Information
Please provide a detailed description of the event for which the applicant is seeking coverage.
What date will the event begin?
MM slash DD slash YYYY
What time will the event begin?
What date will the event end?
MM slash DD slash YYYY
What time will the event end?
Is there a brochure or any promotional material available for this event?
Please upload a copy of the brochure or promotional material, if available.
How many attendees will the event host per day?
What will the total number of attendees be for this event?
How many volunteers will the event have per day?
What is the total number of volunteers this event will have?
Will there be alcohol served at this event?
Who will be serving the alcohol?
Please enter details about who will be serving the alcohol.
Is Liquor Liability coverage desired?
Have you received evidence of Liquor Liability Insurance from the Third Party Vendor?
Liquor Liability
Is liquor served on premises?
Provide details below.
Is staff required to take the Smart Serve or similar course to serve alcohol?
Provide details below.
Is I.D. requested from younger patrons prior to serving them alcohol?
Provide details below.
Do you provide taxi service/transportation for intoxicated patrons?
Provide details below.
Is there a Happy Hour?
Provide details below.
Does the applicant have a bouncer on payroll or a security guard contract in place?
Provide details below.
Has the applicant's liquor license ever been canceled or suspended?
Provide details below.
Has the applicant incurred any liquor violations?
Provide details below.
Is there a liquor inventory system?
Please select the inventory system type.
Is there a back up copy of the inventory?
How often is the liquor inventory checked?
Is there any temperature control equipment/rooms for storage of food and wine?
Are the temperature control equipment/rooms alarmed?
Please provide details of the alarms.
Is there a back up generator?
Please upload a copy of the applicant's liquor license.
What is the expected revenue from admission fees for this event?
What is the expected revenue from liquor sales for this event?
What is the expected revenue from food sales for this event?
What is the expected revenue from merchandise for this event?
Please select the activities that will be present at this event.
Please provide a description of the amusement rides.
Please provide a description of the animal rides.
Please provide a description of the balloon rides.
Please provide a description of the circus being provided.
Please provide a description of the climbing walls.
Please provide a description of the demolition derby.
Please provide a description of the fireworks.
Please provide a description of the food vendors.
Please provide a description of the haunted houses.
Please provide a description of the hay rides.
Please provide a description of the inflatables (bounce houses, etc.)
Please provide a description of the petting zoos.
Please provide a description of the tractor pulls.
Venue Information
What is the name of the venue where this event will be held?
What is the address of the venue where this event will be held?
What is the seating capacity?
What type of seating does the venue offer?
Please enter a description for the type of seating this venue offers.
How many exhibitors will be at this event?
Is this event limited to venue grounds?
Please provide details about where attendees are able to participate in this event besides venue grounds.
Safety & Security Information
Who will be providing security at this event?
Please provide details about who will be providing security?
Has the private security firm provided you will evidence of insurance with the applicant listed as an additional insured.
Please upload a copy of the evidence of insurance, if available.
Please describe the safeguards the Applicant will put in place to prevent injury to spectators.
Please provide a description of the first aid/medical arrangements the Applicant has in place for this event.
Will swimming be part of this event?
Will there be certified lifeguards on duty during the event?
Are the lifeguards CPR trained?
Does the Applicant request CPR certificates from the lifeguards?
Certificate Holders and Additional Insureds
Is the Applicant required to provide certificates of insurance to any other entity?
Is the Applicant required to name the entities as additional insureds?
Please provide the names of all certificate holders and additional insureds along with their interest.
Applicant's Signature
Enter the full name of the person signing this form?
Enter their title.
Draw their signature.
Documents and Comments
Please use this field to upload any relevant insurance documents.
Please enter any additional remarks in the space below.
How did you hear about us?
Please share who referred you to us.
Please share what you typed into Google.
Please share how you heard about us.
Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes. *
