* Indicates required information.

1. * Name of Applicant:

* Address:

* City:
   
* State:
State Outside US / Canada Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Province du Quebec Puerto Rico Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory
* Phone:

Fax:

* E-mail

1.1. * Contact Person:

* Address:

* City:
   
* State:
State Outside US / Canada Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Province du Quebec Puerto Rico Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory
* Phone:

Fax:

E-mail

2. * Dates of event:       
From: am pm to am pm

Dates coverage requested:
from from 12:01am to 12:01am

3. Name of event:

4. * Location of event (name of facility):

* Address:

* City:

* State:
State Outside US / Canada Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Province du Quebec Puerto Rico Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory

5. * Description of event:

Does this event involve a parade? Yes No

Number of units in parade:
(a marching band, a float, a car carrying personalities, etc. is each considered one unit)
Number of floats in parade:
Is anything thrown from any of the floats? Yes    No
If yes, please describe:

Length of parade in blocks:
Length of parade in time:
Estimated number of spectators at parade:

6. How many years has this festival/parade been held?:

7. Additional insured name and address:
a.
Business relationship:

b.
Business relationship:

c.
Business relationship:

d.
Business relationship:

8. Estimated gross receipts (all sources):
Price of admission:

Estimated budget:
Estimated expenses (all sources):

9. * Estimated total attendance:
* Estimated maximum daily attendance:

10. Limits of liability requested per occurrence:
General aggregate:

11. * Will there be any exhibitions, demonstrations, parades or pageants?
Yes No

if yes, describe:

12. Are any of the following additional coverages needed?

Commercial Liquor Liability      Parade Liability

13. Who provides security for this festival/parade?

Venue     City     County     State     Employee    Private Agency

Average number of security officers per festival/parade day:
Private agency must provide Certificate of Insurance naming Promoter as additional insured
(copy must be attached or faxed prior to binding).

14. Number and type of medical personnel:

Paramedic:
EMT/EMS:
Nurse:

Other:

15. Is the festival/parade site in compliance with city, state, county and township building, safety and fire codes?

Yes    No

16. Emergency evacuation (i.e., tornado, bomb threat, etc.):

a. Is there an evacuation plan in place?

b. How is the crowd dispersed from the grounds, parking area, etc?

17. Type of musical entertainment provided:

Hard Rock     Rock     Pop     Jazz     C&W     Classical    
Bluegrass     Folk     Dance/Techno     Other

Please list bands (Or attach list if necessary):

18. Is the Event Indoors  Outdoors

If Outdoors, does the event end ninety minutes prior to sundown?

Yes     No

If NO, is there permanent lighting over all spectator areas and all parking lots?

Yes     No

19. If the event is Outdoors, is the area fenced in or otherwise enclosed?

Yes     No

20. Describe type of seating provided (bleacher, stadium, theatre, folding chairs, etc.)

Is seating  Temporary  Permanent

Type and number of seating during event:

Assigned     Festival     None

21. Are you responsible for parking?

Yes     No

Is lot attended?

Yes     No

22.If a stage is involved, is it Permanent  or  Temporary

If temporary, who is responsible for setup?

(Certificate of insurance, must be provided.)

23. If a tent is involved, who is responsible for set up?

(This policy contains a tent collapse exclusion.)

24. Is temporary lighting involved? Yes     No

Who is responsible for set-up and tear-down?

(Certificate of insurance must be provided.)

25. Are ushers used? Yes     No

If yes, who provides the service?

26. * Who is providing food and/or drink, applicant or other (name)?

If other than applicant, is a certificate of insurance provided? Yes     No

27. * Number of vendors/trade booths:

* Type of goods sold or displayed:

28. * Are vendors/trade booths required to provide a certificate of insurance?
Yes NO

29. * Is applicant providing any overnight camping facilities or other accommodations?
Yes     No

30. Previous three (3) year insurance history must be listed on the application if company loss runs are unavailable:

We also need copies of all lease and hold harmless agreements. 
Certificates requested must be received with premium payment prior to binding.

For Insurance Agents & Brokers only:

Your company name:

First name:

Last name:

Address:

City:

State:
State Outside US / Canada Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Province du Quebec Puerto Rico Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory
Daytime phone:

Mobile phone:

Fax:

E-mail