Special Events Product
|
|
- Felix Kelley
- 6 years ago
- Views:
Transcription
1 USLI.COM Special Events Product YOU ARE VULNERABLE TO SUITS ALLEGING PROPERTY DAMAGE, BODILY INJURY OR MEDICAL PAYMENTS CAUSED BY THE NEGLIGENT OPERATIONS OR ACTIVITIES AT YOUR SPECIAL EVENT. If someone trips and falls at your affair, there is the potential you may be facing a significant lawsuit due to their injuries. Property damage to the venues is the most common type of claim we see on special events. One or several attendees could suffer from serious food poisoning and you may be responsible for their medical expenses. DEPENDING ON THE LAWS IN YOUR STATE, YOU MAY BE HELD LIABLE FOR THE ACTIONS OF INTOXICATED OR UNDERAGE PERSONS YOU SERVED AT YOUR SPECIAL EVENT The negligent service to an intoxicated or underage person can produce substantial verdicts or settlements. Underage drinkers make up a significant portion of alcohol-related traffic crashes. You may also be held responsible for the actions of those selling/serving alcohol for you. Even if you are ultimately cleared of liability, it may cost thousands of dollars to defend a claim. There are many important coverage features you should have in your Special Event Policy. Why you should place coverage with us: COVERAGE FEATURES OUR GROUP COMPETITORS POLICY General Liability Coverage and/or Liquor Liability Coverage available with separate limits? Expense outside policy limits? No deductibles? Coverage for damage to rented premises includes other perils in addition to fire? Property owner can be included as an Additional Insured at no additional premium? Automatic coverage for volunteers, temporary or leased workers and committee members? Extended coverage for events lasting past midnight at no additional premium? Specialized Claims Team? A.M. Best rated A++ carrier? Insure your financial well-being with a stable Company that will be there to pay your claim. This document does not amend, extend or alter the coverage afforded by the Policy. For a complete understanding of any insurance you purchase, you must first read your Policy, Declaration Page and any Endorsements and discuss them with your Broker. A specimen policy is available from an Agent of the Company. Your actual Policy Conditions may be amended by Endorsement or affected by State Laws. SEL-POS 2/13
2 USLI.COM The Main Event Special Event Product We have the ability to provide fast quote turnaround for your Special Events. Eligible classes can be covered for General Liability, Liquor Liability or both! Product Features: u General Liability Coverage and/or Commercial Liquor Liability coverage available for events with up to 10,000 attendees per day on most risks u Separate limits for General Liability and Host Liquor Liability u The Host - Host Liquor Liability available for one-day events with 500 or less attendees in many states u Automatic coverage for volunteers, temporary or leased workers, and committee members u Food and beverage Product Liability included in the General Aggregate u Medical Payments coverage u Coverage for damage to rented premises u Property owner can be included as Additional Insured at no charge u No deductible Great Coverage for: u Beer Gardens/Beer Tents, Concerts/Musical Performances, Festivals, Parties, Sporting Events, Motor Vehicle Events, Car Shows, Conventions/Trade Shows/Exhibits, Fund Raisers, Parades, Picnics, Weddings/Receptions and many other miscellaneous events Limits of Liability: u Limits of $1,000,000/$2,000,000 available u Limits of $3,000,000/$3,000,000 available on certain risks Additional Advantages: u Low minimum premium u A.M. Best rated A++ carrier u Online quote, bind and issue system This document does not amend, extend or alter the coverage afforded by the Policy. For a complete understanding of any insurance you purchase, you must first read your Policy, Declaration Page and any Endorsements and discuss them with your Broker. A specimen policy is available from an Agent of the Company. Your actual Policy Conditions may be amended by Endorsement or affected by State Laws. SEL-NR 7/12
3 Special Event Product Claim Examples General Liability: Claimant attended a golf tournament and tripped over a sprinkler head. She suffered a fractured knee cap, and needed reconstructive surgery. Medical bills totaled $10,000. General Liability: Insured was holding a basketball tournament at a YMCA. During the game the gymnasium floor was damaged. Property owner held the insured liable for the property damages totaling $10,200. General Liability: Insured held a theater performance at a local high school auditorium. Fake blood was used for a special effect, and the fake blood damaged the curtains in the auditorium. The property owner of the facility is suing the insured for the damage to the curtains totaling $7,500. Liquor Liability: A minor attendee was served alcohol at a brew festival sponsored by the insured. After leaving the festival, the underage attendee got into his car, lost control of his vehicle and struck a telephone pole. He suffered severe facial lacerations. The attendee is suing the event sponsor and the beer vendor for illegal service to a minor to cover his medical bills totaling $150,000. Host Liquor Liability: An attendee was drinking heavily at a holiday party hosted by the insured. While driving home, the attendee lost control of her vehicle and hit a tractor-trailer head on. The driver of the truck suffered severe injuries. The driver brought suit against the host of the party for negligence in serving the intoxicated guest. The driver s injuries total $300,000. This document does not amend, extend or alter the coverage afforded by the Policy. For a complete understanding of any insurance you purchase, you must first read your Policy, Declaration Page and any Endorsements and discuss them with your Broker. A specimen policy is available from an Agent of the Company. Your actual Policy Conditions may be amended by Endorsement or affected by State Laws. SEL CLA (11/06)
4 USLI.COM The Main Event Special Event Product You can obtain a quote by providing the information in the INSTANT QUOTE section, subject to the remainder provided prior to binding. I. INSTANT QUOTE INFORMATION Instant Quote is only available for accounts with no losses in the past three years. If there is loss history, please detail the losses below. TYPE OF EVENT q Beer garden/beer tent q Fundraiser q Individual vendor booth q Car show q Motor vehicle race/show q Picnic q Concerts/Musical performance q Competition or shows q Sporting event/tournament q Conventions/Trade show/exhibit q Parade q Wedding/Wedding reception q Festival q Party/Social event q Other (describe): Name of applicant: (List only one legal & dba name. Do not include etal, etc. or other similar wording in the name.) Describe applicant s role and responsibility in event: Location address: q Same as mailing address City: State: Zip: Dates of event: From: / / To: / / (If one day event, end date should be the same as start date. Quote will contemplate coverage for events continuing past 12:00 AM) Desired coverage date(s): From: / / To: / / If event date(s) differs from desired coverage date(s), explain: Is set-up and take-down coverage needed for additional dates? q Yes* q No *If Yes, what are the dates and what will this exposure include? *Will there be any heavy machinery used such as bulldozer s, backhoes, excavators, or any other types of industrial machinery (small forklifts and light machinery are acceptable)? q Yes q No Would you like to include a rain date? q Yes* q No *If Yes, what date? FULL SCHEDULE/DESCRIPTION AND PURPOSE OF EVENT (Attach copy of brochure, website pages and flyer to this application or include details on all activities taking place): Will there be any entertainment? q Yes* q No *If Yes, describe and include name of performers and acts: Is there a Web site for this event? q Yes* q No *If Yes, provide Web site address: Name of additional insured: Mailing address: Additional insured s interest in event: Coverage desired: q Commercial general liability and liquor liability q Commercial general liability only q Liquor liability only Limits of coverage desired: COMMERCIAL GENERAL LIABILITY ESTIMATED TOTAL ATTENDEES PER DAY: If applicant is an individual exhibitor/vendor, what is the estimated attendees per day anticipated to visit their booth? Average age of attendees: LIQUOR LIABILITY (IF COVERAGE IS DESIRED) Hours of event: From: AM/PM To: AM/PM If hours vary by date, describe: ESTIMATED NUMBER OF ATTENDEES CONSUMING ALCOHOL DAILY: Is the applicant in the business of selling, serving or furnishing alcoholic beverages? q Yes q No Is the applicant required to have a liquor license for the event (excluding licenses that are restricted to a host liquor exposure where event sales are not for personal monetary gain)? q Yes q No SELA-6/09 page 1 of 4
5 II. HISTORY 1. Previous carrier: Policy number: 2. Losses or claims during the past five years: III. LIQUOR LIABILITY 1. a. Is applicant the sole vendor/server of alcohol at event? q Yes q No* *If No, list number of other vendors/servers serving alcohol: b. If there are multiple vendors, are all participating alcohol vendors/servers required to carry liquor liability limits for the event equal to or greater than our applicant? q Yes q No 2. Will alcohol be dispensed by a professional bartender or server that has taken a formal alcohol awareness training course? q Yes q No 3. Will alcohol be sold by applicant? q Yes q No 4. Is BYOB (Bring Your Own Bottle) or self-service of alcohol permitted? q Yes q No IV. COMMERCIAL GENERAL LIABILITY 1. Will event feature any of the following: a. Mechanical rides/devices? q Yes q No b. Moon bounce, rock climbing wall, trampoline or similar rebounding devices, petting zoo or animal rides? q Yes * q No *(Please Note: Our policy specifically excludes injuries arising from moon bounces, trampolines, rock walls, petting zoos and pony rides). c. Firearms or fireworks? q Yes q No d. Overnight camping? q Yes q No e. Water hazards? q Yes* q No *If Yes, describe: *Will attendees be permitted to swim, boat, jet ski or fish? q Yes* q No *If Yes, describe: 2. Will the event use exhibitors, vendors, performers, contractors, sub-contractors or independent contractors? q Yes* q No *(Please note, injuries arising from exhibitors, vendors, performers, contractors, sub-contractors or independent contractors are excluded from our policy). 3. a. Describe security measures: b. If security is provided by independent contractors, are they required to carry their own insurance? q N/A q Yes q No 4. If this is a CONCERT/MUSICAL EVENT, complete below: (Please note, coverage for injury to performers and entertainers is excluded from our policy). a. Name(s) of performer(s): Describe type of music: b. Performers are: q Local q National c. Will pyrotechnics be featured? q Yes q No d. Any special effects? q Yes* q No *If Yes, describe: 5. If this is a PARADE EVENT, complete below: (Please note, coverage for injury to parade participants is excluded from our policy). a. Has parade route been approved by local authorities and will route be secured by police? q Yes q No* *If No, explain: b. Are parade participants permitted to throw souvenirs, candy or other items into the crowd? q Yes q No c. Describe parade route from start to finish: 6. If this is an ATHLETIC EVENT, complete below: (Please note, coverage for injury to athletic participants is excluded from our policy). a. Describe athletic event: b. q Professional or q Amateur 7. If this is a MOTOR VEHICLE RACE, RODEO, TRACTOR PULL OR TRUCK SHOW, complete below: (Please note, coverage for injury to participants is excluded from our policy). a. Is the venue designed specifically for this type of activity? q Yes q No b. Are metal or concrete barriers in place to ensure spectator safety? q Yes q No* *If no, describe: c. Are the barriers permanent? q Yes q No d. How high are the barriers? What is the distance between the barriers and spectators? e. Are spectators ever permitted in the pit or infield area? q Yes q No f. If this is a rodeo, are the transfer areas between animal pens and the competition restricted from the general public? q Yes q No g. Will the event feature audience participation (i.e. calf scrambles)? q Yes q No SELA- 6/09 - United States Liability Insurance Group page 2 of 4
6 8. If this is a HEALTH FAIR/CONVENTION, complete below: a. Will the event feature any medical or health treatment? q Yes q No 9. If this is a CAR SHOW/MOTOR VEHICLE SHOW, complete below: (Please note, coverage for injury to participants is excluded from our policy) a. Do vehicles remain stationary throughout the show with the engines off? q Yes q No b. Will the event feature burnouts, drag races or flame throwing? q Yes q No V. ADDITIONAL APPLICANT INFORMATION Form of business: q Individual q Corporation q Partnership q LLC q Other Applicant s mailing address: (if different than the location address above) City: State: Zip: address of primary contact: Phone: Virginia Notice: Statements in the application shall be deemed the insured s representations. A statement made in the application or in any affidavit made before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly proven that such statement was material to the risk when assumed and was untrue. Minnesota Notice: The clause and/or authorization or agreement to bind the insurance. is replaced with Authorization or agreement to bind the insurance may be withdrawn or modified based on changes to the information contained in this application prior to the effective date of the insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10 days notice given to the insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for nonpayment of premium. Colorado Fraud Statement: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. District of Columbia Fraud Statement: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Florida Fraud Statement: You are agreeing to place coverage in the surplus lines market. Superior coverage may be available in the admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act with respect to any right of recovery for the obligation of an insolvent unlicensed insurer. Kentucky Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Maine and Washington Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. New York Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Ohio Fraud Statement: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Oklahoma Fraud Statement: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Pennsylvania Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Tennessee and Virginia Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Fraud Statement (All Other States): Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison. SELA- 6/09 - United States Liability Insurance Group page 3 of 4
7 Applicant s signature: Title: Date: If your state requires that we have information regarding your authorized retail agent or broker, please provide below. Retail agency name: License #: Main agency phone number: Agency mailing address: City: State: Zip code: SELA- 6/09 - United States Liability Insurance Group page 4 of 4
The Main Event Special Event Product
New England Excess Exchange, Ltd. PO Box 650 - Barre, VT 05641 800-548-4301 - Fax 800-347-4935 www.neee.com - info@neee.com The Main Event Special Event Product USLI.COM 888-523-5545 YOU CAN OBTAIN A QUOTE
More informationSPECIAL EVENT SUPPLEMENTAL APPLICATION
SPECIAL EVENT SUPPLEMENTAL APPLICATION SUBMISSION REQUIREMENTS Currently valued insurance company loss runs for the current policy period plus three (3) prior years (for accounts where premium exceeds
More informationName Relationship/Interest Address City, State, Zip
USLI.COM 888-523-5545 Catering Plus Liquor Liability Warranty Application Banquet Halls, Bartending Services, Caterers, Concessionaires YOU CAN OBTAIN A QUOTE BY PROVIDING THE INFORMATION IN SECTION I
More informationSpecial Event Liability Application
Specialty Group 401 Edgewater Place, Suite 400 Wakefield, MA 01880 USA Tel: 781-994-6000 Fax: 781-994-6001 E-mail: EventLiability@tmhcc.com Special Event Liability Application A. INSURED INFORMATION 1.
More informationSPECIAL EVENT LIABILITY APPLICATION
SPECIAL EVENT LIABILITY APPLICATION A. INSURED INFORMATION 1. 2. 3. Insured Company Name (Applicant): Contact Name: Address: 4. City: State: Zip Code: 5. Phone: Fax: E-mail: 6. No. Years in Operation:
More informationSpecial Event Application
Special Event Application Complete section(s) applicable to the type of event being held. Application must be signed and dated by the applicant. Applicant s Name Agent Applicant Mailing Address Applicant
More informationEnclosed you will find an admitted Commercial Liability quote for Medshare International, Inc.. The quote number is MSE017J3971 Version 8.
POINTENORTH INSURANCE GROUP, LLC. P.O. Box 724728 Atlanta, GA 31139 dmckinney@pointenorthins.com Phone: (770) 858-7540 Fax: (770) 858-7545 Enclosed you will find an admitted Commercial Liability quote
More informationI GENERAL INFORMATION
PEST CONTROL PROGRAM EMPLOYMENT PRACTICES LIABILITY INSURANCE APPLICATION THIS APPLICATION IS FOR A CLAIMS-MADE POLICY. PLEASE READ YOUR POLICY CAREFULLY Applicant may qualify for a QUICK QUOTE by completing
More informationCorporate Directors and Officers Liability, Employment Practices Liability and Fiduciary Liability
USLI.COM 888-523-5545 Corporate Directors and Officers Liability, Employment Practices Liability and Fiduciary Liability THE ANSWER All questions must be answered and application must be signed by the
More informationLiquor Liability Special Event Application
Liquor Liability Special Event Application Complete a separate application for each event. Applicant s Name: Agency Name: Agent: Mailing Address: Address: Event Location: E-Mail: Phone: Website Address:
More informationIn addition to the $2,000,000 of aggregate coverage, this Plan also pays all court and legal defense costs for a covered claim.
AMERICAN FEDERATION OF MUSICIANS Musicians Liability Insurance Plan. providing up to $2,000,000 aggregate coverage each year! THE SOLUTION FOR MUSICIANS LIABILITY PROBLEMS Many facilities now require musicians
More informationCARRIER: Applicant s name: City: State: Zip code: Website address: address of primary contact:
CARRIER: This application is for a Claims Made policy. Please read your policy carefully. Defense costs shall be applied against the deductible (except in New York). Applicant may qualify for an INSTANT
More information1. Producer Number: 2. Event Type:
1. Producer Number: 2. Event Type: SPECIAL EVENTS LIQUOR LIABILITY / GENERAL LIABILITY APPLICATION 1111 E. Touhy Ave., Suite 300 Des Plaines, IL 60018 Toll Free Tel: (800) 972-8778 Fax :(847) 795-0061
More informationCraft Beverage Insurance Program: Microbrewery / Distillery Supplemental Application
Named Insured: DBA: Mailing Address: Location Address: Website Address: Inspection Contact Name: Email Address: Inspection Contact Phone Number: Insured Type: Individual Partnership Corporation Other Proposed
More informationSPECIAL EVENT APPLICATION
1. Named Insured (applicant): 2. Mailing Address: 3. City: State: Zip: Phone: 4. Name of Event: Location of Event: (name of facility, city, state) 5. Description of Event, including schedule (attach brochure
More informationSpecified Professions Professional Liability Product
COMMITTED TO A MAKING DIFFERENCE Specified Professions Liability Product SPECIFIED PROFESSIONS PROFESSIONAL LIABILITY APPLICATION This is an application for a claims made policy. Please read your policy
More informationDate of Violation Type of Violation Action taken to prevent future Violations
SIS Wholesale Insurance Services 4. List types of entertainment and how often featured: Band (other than jazz/instrumental) times per week times per year DJ times per week times per year Other (describe):
More informationIRONSHORE INSURANCE INC. One State Street Plaza, 8 th Floor New York, NY Tel: Toll Free: (877) IRON-411
IRONSHORE INSURANCE INC. One State Street Plaza, 8 th Floor New York, NY 10004 Tel: 646-826-6600 Toll Free: (877) IRON-411 CONSULTANTS PROFESSIONAL LIABILITY INSURANCE APPLICATION THE APPLICANT IS APPLYING
More informationMONOLINE LIQUOR LIABILITY APPLICATION
MONOLINE LIQUOR LIABILITY APPLICATION GENERAL APPLICANT INFORMATION: Applicant s name: Mailing address: City: State: Zip: E mail address of primary contact: Website address: Phone number: Inspection contact
More informationThe HAM Radio Club Liability Insurance Plan Protects what your club has worked hard to accomplish!
The HAM Radio Club Liability Insurance Plan Protects what your club has worked hard to accomplish! One Plan Complete Protection This Plan provides extensive coverage for lawsuits resulting from bodily
More informationDBA: 2. Address 1: Address 2: 3. City: State: Zip Code: Number of days needed for coverage?
LIQUOR LIABILITY Application Instructions A. Please type or complete the application in ink. B. If additional space is needed; please use your firm s letterhead. Instant Indication A. Applicant Information
More informationLexington Insurance Company SM
LIQUOR LIABILITY INSURANCE APPLICATION Application Instructions A. Please type or complete the application in ink. B. If additional space is needed, please use your firms letterhead. Instant Indication
More informationAXIS PRO MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION FOR STANDARDS AND SPECIFICATIONS
SPONSORED BY: AMERICAN SOCIETY OF ASSOCIATION EXECUTIVES AXIS PRO MISCELLANEOUS PROFESSIONAL LIABILITY APPLICATION FOR STANDARDS AND SPECIFICATIONS WHAT THE APPLICANT SHOULD KNOW ABOUT THIS APPLICATION
More informationOFF PREMISES LIQUOR LIABILITY APPLICATION
Applicant's Name: Applicant Mailing Address: Proposed Policy Period: OFF PREMISES LIQUOR LIABILITY APPLICATION TO BE COMPLETED IN ADDITION TO ACORD APPLICATION OR ITS EQUIVALENT All questions must be answered
More informationUNITED STATES LIABILITY INSURANCE GROUP Private Investigator & Background Checking/Screening Service Supplemental A P P L I C A T I O N
UNITED STATES LIABILITY INSURANCE GROUP Private Investigator & Background Checking/Screening Service Supplemental A P P L I C A T I O N Applicant s Name: If the Applicant is newly established, please provide
More informationAIG INSURANCE SPORTS GENERAL LIABILITY CAMP/CLINIC/SPECIAL EVENT/TOURNAMENT APPLICATION DBA: 3. Mailing Address: Physical Address 2:
AIG INSURANCE SPORTS GENERAL LIABILITY CAMP/CLINIC/SPECIAL EVENT/TOURNAMENT APPLICATION Application Instructions A. Please type or complete the application in ink. B. If additional space is needed, please
More informationLIQUOR LIABILITY PRODUCT APPLICATION
LIQUOR LIABILITY PRODUCT APPLICATION GENERAL APPLICANT INFORMATION: Applicant s name: Mailing address: City: State: Zip: E mail address of primary contact: Website address: Phone number: Inspection contact
More informationSpecified Professions Professional Liability Product
Specified Professions Professional Liability Product SPECIFIED PROFESSIONS PROFESSIONAL LIABILITY APPLICATION This is an application for a claims made policy. Please read your policy carefully. Quaker
More informationVENUE APPLICATION INSURED SUB-CONTRACTED* OTHER (DESCRIBE)
VENUE APPLICATION Facility Name: Facility Age: Contact Person: Facility Location: Title: (Please indicate nearest highway intersection if no address) Phone: Fax: Website: Effective Date: Expiration Date:
More informationLiquor Liability Application
Liquor Liability Application Complete a separate application for each location. Applicant s Name Agency Name Agent Mailing Address Address Location Address E-Mail Phone Web site Address PROPOSED EFFECTIVE
More informationPersonal Lines Insurance Agents Professional Liability
Personal Lines Insurance Agents Professional Liability WHY YOU NEED TO BUY PROFESSIONAL LIABILITY COVERAGE NOW: Insurance agents and brokers are uniquely exposed to both claims frequency and claims severity
More informationSpecified Professions Professional Liability Product
COMMITTED TO A MAKING DIFFERENCE Specified Professions Liability Product SPECIFIED PROFESSIONS PROFESSIONAL LIABILITY APPLICATION This is an application for a claims made policy. Please read your policy
More informationHospitality Application
Hospitality Application Named Insured: DBA: Mailing Address: Location Address: Website Address: Inspection Contact Name: Email Address: Inspection Contact Phone Number: Insured Type: Individual Partnership
More informationCraft Beverage Insurance Program: Brew Pub Supplemental Application
Craft Beverage Insurance Program: Brew Pub Supplemental Application Named Insured: DBA: Mailing Address: Location Address: Website Address: Inspection Contact Name: Email Address: Inspection Contact Phone
More informationACE Privacy Protection Privacy & Network Liability Insurance Program Renewal Application
ACE Privacy Protection Privacy & Network Liability Insurance Program Renewal Application NOTICE The Policy for which you are applying is written on a claims made and reported basis. Only claims first made
More informationI. APPLICANT INFORMATION
INVESTMENT BANKING ENGAGEMENT ERRORS AND OMISSIONS INSURANCE APPLICATION This is an Application for claims made and reported Investment Banking Engagement Errors and Omissions Insurance. Please submit
More informationR-T SPECIALTY, LLC Transit Road Depew, NY (716) ext. Ext 4837 Fax: (716)
R-T SPECIALTY, LLC 6450 Transit Road Depew, NY 14043 (716) 856-3065 ext. Ext 4837 Fax: (716) 856-8057 Enclosed you will find an admitted General Liability/Liquor Liability Special Event quote for North
More informationSUPPLEMENTAL APPLICATION FOR PROFESSIONAL EMPLOYER ORGANIZATIONS AND TEMP FIRMS
SUPPLEMENTAL APPLICATION FOR PROFESSIONAL EMPLOYER ORGANIZATIONS AND TEMP FIRMS NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND REPORTED POLICY SUBJECT TO ITS TERMS. THIS POLICY
More informationLexington Insurance Company
RAILROAD PROTECTIVE LIABILITY APPLICATION Application Instructions A. Please type or complete the application in ink. B. If additional space is needed, please use your firms letterhead. Instant Indication
More informationClub & Chapter Liability Insurance Plan
Club & Chapter Liability Insurance Plan Protect your organization s resources against a costly lawsuit! One Plan Complete Protection The plan provides extensive coverage for lawsuits resulting from bodily
More informationPROPOSED INSURED (APPLICANT):
PROPOSED INSURED (APPLICANT): 1. Name of the Applicant s firm: Street Address: City, State, Zip Code: Website address(es): 2. A. Provide the date the Applicant s firm was established: B. Geographic area
More informationSpecial Events Application
About This Program This application is used to insure a single event taking place in the United States or Canada. Required Documents The following documents are required to apply for coverage: This application
More informationMiscellaneous Professional Liability Application
AMERICAN INTERNATIONAL COMPANIES Name of insurance company to which Application is made (the Insurer ) Miscellaneous Professional Liability Application NOTICE: THE POLICY PROVIDES THAT THE LIMIT OF LIABILITY
More informationAdvertising agency, marketing and communications application
Notice: This insurance coverage provides that the policy limit available to pay damages shall be reduced by amounts incurred for defense costs, and may be completely exhausted by such amounts. We shall
More informationINCLUDE PREMISES LIABILITY 1 Yes No 2 Yes No 3 Yes No 4 Yes No 5 Yes No OWNED OR RENTED
Arceri & Associates, Inc. Insurers of Mardi Gras Since 19 www.arceri-insurance.com Parade/Event Application (0) 8-9 Phone (800 11-71 Fax chris@arceri-insurance.com Applicant s Full Legal Name, including
More informationEquine Commercial General Liability
All American Horse Insurance PO Box 300384 Glenwood, UT 84730 Phone 435-896-4593 fax 435-893-0920 allamericanhorseinsurance@gmail.com Equine Commercial General Liability Producer: Policy and/or Renewal
More informationPart One Small Firm Application for Miscellaneous Professionals Liability
Part One Small Firm Application for Miscellaneous Professionals Liability Contractors Bonding and Insurance Company Peoria, Illinois 61615 This application applies to firms with revenues less than $1,000,000.
More informationPersonal Lines Insurance Agents Professional Liability
Buschbach Insurance Agency, Inc. 5615 W. 95 th Street P.O. Box 5000 Oak Lawn, Illinois 60455-5000 Phone: (708)424-0100 Fax: (708)425-5077 Personal Lines Insurance Agents Professional Liability INSURANCE
More informationLiquor Liability Application
Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Scottsdale Surplus Lines Insurance Company Scottsdale Indemnity Company Home Office: One Nationwide Plaza Columbus, Ohio
More informationHIRED AND NON-OWNED AUTOMOBILE SUPPLEMENTAL APPLICATION
HIRED AND NON-OWNED AUTOMOBILE SUPPLEMENTAL APPLICATION PLEASE ANSWER ALL QUESTIONS IF THEY DO NOT APPLY, INDICATE NOT APPLICABLE (N/A) Applicant Name: HIRED AUTO INFORMATION Coverage Subject to Audit
More informationTechnology Professional Liability Product
Quaker Special Risk P.O. Box 1350 Eatontown, NJ 07724 Phone: 800 447-4180 Fax: 732 223 9072 Technology Professional Liability Product TECHNOLOGY PROFESSIONAL LIABILITY APPLICATION All questions must be
More informationSPECIAL EVENTS APPLICATION
Surplus Insurance Brokers Agency Inc. GENERAL INFORMATION 1. First Named Insured SPECIAL EVENTS APPLICATION Call 800-342-5706 Fax 800-578-7758 www.surplusins.com Email quotes: submit@surplusins.com P O
More informationWAGE AND HOUR COVERAGE ENHANCEMENT SUPPLEMENTAL APPLICATION
WAGE AND HOUR COVERAGE ENHANCEMENT SUPPLEMENTAL APPLICATION NOTICE TO NEW YORK APPLICANTS: The Policy for which this Application is made is a claims made Policy. Upon termination of coverage for any reason,
More informationApplication for Lender Environmental Collateral Protection and Liability Insurance for Loan Portfolios
Application for Lender Environmental Collateral Protection and Liability Insurance for Loan Portfolios Instructions 1. All questions must be answered 2. If space is insufficient, attach additional sheets
More informationNot for Profit Directors & Officers Insurance Application
Not for Profit Directors & Officers Insurance Application This is an application form for a Claims Made Insurance Policy for Directors and Officers Liability Insurance (D&O), including Employment Practices
More informationRailroad Protective Liability Coverage (Attach/Submit ACORD 801)
1. Applicant Information: A. Name Insured Railroad: Railroad Protective Liability Coverage (Attach/Submit ACORD 801) 1. DBA: 2. Address: 3. City: State: Zip Code: B. Name Designated Contractor: 1. DBA:
More informationCONSTABLE PROFESSIONAL LIABILITY APPLICATION
CONSTABLE PROFESSIONAL LIABILITY APPLICATION Provide responses to the inquiries on this application. If necessary, provide detailed responses on the last page. I. APPLICANT INFORMATION 1. Name : Address:
More informationEquestrian Homeowner, Ranch & Estate Program Renewal Application
Equestrian Homeowner, Ranch & Estate Program Renewal Application Producer: Number: Last Year s Policy #: Expiration Date: Requested Effective Date: Submit early to avoid any lapse in coverage. Incomplete
More informationAPPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE
APPLICATION FOR EMPLOYMENT PRACTICES LIABILITY INSURANCE NOTICE: THE POLICY FOR WHICH APPLICATION IS MADE APPLIES ONLY TO CLAIMS FIRST MADE DURING THE POLICY PERIOD AND REPORTED TO THE COMPANY DURING THE
More informationExecPro Proposal Form for Fiduciary Liability Insurance
sm ExecPro Proposal Form for Fiduciary Liability Insurance FIDUCIARY PROPOSAL FORM Name of Company: Street Address: City, State, Zip: Internet Website Address: Please list the officer designated as agent
More informationSpecial Events Liability Insurance. Optional Liquor Liability Coverage Available
Special Events Liability Insurance Optional Liquor Liability Coverage Available 4-H Clubs Antique Shows Auctions Banquets Bazaars Beauty Contests Consumer Shows Contests Demolition Derbies Educational
More informationPersonal Lines Insurance Agents Professional Liability
COMMITTED TO A MAKING DIFFERENCE Personal Lines Insurance Agents Professional Liability INSURANCE AGENTS AND BROKERS PROFESSIONAL LIABILITY APPLICATION All questions must be answered and application must
More informationLIQUOR LIABILITY APPLICATION
LIQUOR LIABILITY APPLICATION TO BE COMPLETED IN ADDITION TO ACORD APPLICATION OR ITS EQUIVALENT All questions must be answered in full. If necessary, attach a separate sheet of paper with complete details.
More informationAny losses in the past 3 years? If yes, provide details below. Yes No Policy Type Carrier Policy # Expiration Date Premium / / / /
About This Program This application is used to insure a venue for the events that take place at the venue. Required Documents The following documents are required to apply for coverage: This application
More informationAbuse And Molestation Liability Application
Abuse And Molestation Liability Application THIS APPLICATION IS ON AN OCCURRENCE COVERAGE BASIS THIS APPLICATION IS ON A CLAIMS-MADE COVERAGE BASIS NOTICE: THIS APPLICATION IS FOR A COVERAGE PART WRITTEN
More informationFAIRS & FAIRGROUNDS APPLICATION
FAIRS & FAIRGROUNDS APPLICATION BROKER INFORMATION Broker/Agency Name: Address: Street: City: State: Zip: Contact Person: Phone # Fax # E-Mail: Website: GENERAL APPLICANT INFORMATION Business Name: Address:
More informationDate of survey: Renewal Date: Date proposal needed: Legal Name of Organization: (Include all organizations that are to be included as insureds)
ARCHERY RANGES APPLICATION P.O. Box 5670 Cortland, NY 13045 Phone: (800) 822-3747 Fax: (607) 756-5051 Email: applications@ mcneilandcompany.com GENERAL INFORMATION Date of survey: Renewal Date: Date proposal
More informationAXIS PRO MPL SOLUTIONS APPLICATION
AXIS PRO MPL SOLUTIONS APPLICATION WHAT THE APPLICANT SHOULD KNOW ABOUT THIS APPLICATION: CLAIMS MADE POLICY This application is for a CLAIMS MADE POLICY. Claims made coverage applies only to those claims
More informationMember Companies of American International Group, Inc. Name of Insurance Company To Which Application is Made
Member Companies of American International Group, Inc. Name of Insurance Company To Which Application is Made Name of Insurance Company to which Application * is made (herein called the Insurer ) TRUST
More informationEVENT PARTY OR WEDDING PLANNER SUPPLEMENTAL APPLICATION
EVENT PARTY OR WEDDING PLANNER SUPPLEMENTAL APPLICATION Applicant s Name TO BE USED WITH COMMERCIAL GENERAL LIABILITY APPLICATION (ACORD 125) All questions must be answered in full. Application must be
More informationMPL SECURE: MISCELLANEOUS PROFESSIONAL AND NETWORK SECURITY LIABILITY INSURANCE POLICY
RENEWAL APPLICATION AFB MEDIA TECH PROFESSIONAL AND TECHNOLOGY BASED SERVICES, TECHNOLOGY PRODUCTS, COMPUTER NETWORK SECURITY, AND MULTIMEDIA AND ADVERTISING LIABILITY INSURANCE POLICY MISCELLANEOUS PROFESSIONAL
More informationOwner s/tenant s Protective Product
USLI.COM 888-523-5545 Owner s/tenant s Protective Product OWNER S/TENANT S PROTECTIVE PRODUCT APPLICATION Please complete all sections of this application and have signed by the applicant. NOTE: Products/Completed
More informationINFORMATION NEEDED FOR A QUOTE
IWA RESTAURANT SUPPLEMENTAL APPLICATION PLEASE SUBMIT ELECTRONICALLY TO: info@iwains.com OR FAX to 631-913-6033 INFORMATION NEEDED FOR A QUOTE Acord Restaurant Supplemental 4 years of Currently Valued
More informationPLEASE READ THE POLICY CAREFULLY
CRIME INSURANCE APPLICATION - MASSACHUSETTS PLEASE READ THE POLICY CAREFULLY Please fully answer all questions and submit all requested information. Terms
More information111 Warren Road - Suite 1B Cockeysville, MD CALL: FAX:
111 Warren Road - Suite 1B Cockeysville, MD 21030 CALL: 1-800-759-7779 FAX: 410-628-6914 http://www.interstate-insurance.com BEAZLEY MISCELLANEOUS PROFESSIONAL LIABILITY INSURANCE APPLICATION NOTICE: THE
More informationAPPRAISAL MANAGEMENT COMPANY PROFESSIONAL LIABILITY APPLICATION
Lexington Insurance Company Administrative Offices: 99 High Street, Floor 23 Boston, Massachusetts 02110-2378 SEND APPLICATIONS AND INQUIRIES TO: 1438-F West Main Street, Ephrata, PA 17522-1345 800.640.7601;
More informationInstructions. Please submit the following information in addition to this application.
Email: aputankadvantage@amwins.com Fax: (717) 214-2801 Dealer Pollution Advantage Coverage Application This application is for a policy providing coverage on a claims made and reported basis. If Financial
More informationSenior Living Professional and General Liability Main Application
Senior Living Professional and General Liability Main Application THIS IS AN APPLICATION FOR PROFESSIONAL LIABILITY, GENERAL LIABILITY, EMPLOYEE BENEFITS LIABILITY AND SEXUAL MISCONDUCT LIABILITY COVERAGE
More informationPRIZE INDEMNIFICATION APPLICATION
Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Scottsdale Indemnity Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Scottsdale Surplus Lines Insurance
More informationProperty/Casualty Insurance Renewal Survey
P.O. Box 5670 Cortland, NY 13045 Phone (800) 822-3747 Fax: (607) 756-5051 Email: applications@ mcneilandcompany.com GENERAL INFORMATION Date of survey: Renewal Date: Date proposal needed: Legal Name of
More informationPRIVATE COMPANY SUPPLEMENTAL CLAIM FORM
PRIVATE COMPANY SUPPLEMENTAL CLAIM FORM Name of Insurance Company to which application is made INSTRUCTIONS: This form is to be completed by an Applicant who has been involved in any claim or suit during
More informationEquine Commercial General Liability Argonaut Insurance Company
Equine Commercial General Liability Argonaut Insurance Company Exclusivley Underwritten By Broker: Broker Number: Broker License Number: Policy and/or Renewal #: Requested Effective Date: Incomplete applications
More informationXL Eclipse 2.0 Renewal Application
XL Eclipse 2.0 Renewal Application Third Party Coverage Technology & Miscellaneous Professional Services Technology Products Media Communications Network Security Privacy Liability First Party Coverage
More informationEMPLOYMENT PRACTICES LIABILITY INSURANCE RENEWAL APPLICATION
EMPLOYMENT PRACTICES LIABILITY INSURANCE RENEWAL APPLICATION NOTICE: THE POLICY FOR WHICH THIS APPLICATION IS MADE IS A CLAIMS MADE AND REPORTED POLICY SUBJECT TO ITS TERMS. THIS POLICY APPLIES ONLY TO
More informationIF YES TO THE ABOVE, PLEASE RESPOND TO THE FOLLOWING QUESTIONS. IF NO, PLEASE SIGN, DATE AND RETURN TO THE UNDERWRITER.
Hartford Fire Insurance Company UNDERWRITING QUESTIONNAIRE SERVICING CONTRACTORS NAME OF INSURED: 1. Do you currently use independent contractors for servicing loans? IF YES TO THE ABOVE, PLEASE RESPOND
More informationFlea Markets/Swap Meets/Bazaars General Liability Application
P.O. Box 14770, Scottsdale, AZ 85267-4770 8475 E. Hartford Dr., Scottsdale, AZ 85255 (480) 991-7889 WATS (800) 848-8860 Fax (480) 948-1394 Toll Free (866) 240-8807 P.O. Box 571770, Murray, UT 84157-1770
More informationHired and Non-Owned Liability Supplemental Application All questions must be answered in full. Application must be signed and dated by the applicant.
Agency Name: Address: Contact Name: Phone: Fax: Email: Applicant s Name Hired and Non-Owned Liability Supplemental Application All questions must be answered in full. Application must be signed and dated
More informationConvenience, Delicatessen, Grocery and Liquor Stores Product
Convenience, Delicatessen, Grocery and Liquor Stores Product CONVENIENCE, DELICATESSEN, GROCERY AND LIQUOR STORES WARRANTY APPLICATION To receive a quote, please complete the General Information Section
More information1. Effective Date: To. 5. Legal Name: DBA: Premise Address: Contact Name: Title: Phone: Alt Phone: (Street) (City) (State) (Zip)
Liquor Liability email: info@uigusa.com phone: 800.385.9978 COVERAGE REQUESTED 1. Effective Date: To 2. Limits of liability $150,000 Split Limit (Minimum coverage required by IABD regulation. Includes
More informationVIRTUE GUARD VIRTUE RISK PARTNERS
VIRTUE GUARD VIRTUE RISK PARTNERS www.virtuerisk.com RENEWAL APPLICATION FOR STORAGE TANK & ENVIRONMENTAL IMPAIRMENT LIABILITY INSURANCE This renewal application is for an insurance policy providing coverage
More informationCommercial General Liability Application
Commercial General Liability Application All questions must be answered in full. Application must be signed and dated by the applicant. Applicant s Name Agent Applicant Mailing Address Applicant s Phone
More informationSUPPLEMENT FOR EMPLOYMENT RELATED SERVICES
SUPPLEMENT FOR EMPLOYMENT RELATED SERVICES All questions MUST be completed in full. If space is insufficient to answer any question fully, attach a separate sheet. 1. Applicant s Name: Location Address:
More informationEquine Commercial General Liability
Equine Commercial General Liability Exclusivley Underwritten By Broker: Broker Number: Broker License Number: Policy and/or Renewal #: Requested Effective Date: Incomplete applications will be returned
More informationCaterers and Halls General Liability and Miscellaneous Articles Application
Caterers and Halls General Liability and Miscellaneous Articles Application Applicant s Name: Agency Name: Agent: Mailing Address: Address: E-Mail: Location Address: Phone: Web site Address: PROPOSED EFFECTIVE
More informationConsultants Liability Application
*Please visit www.allrisks.com/submit-a-risk or contact your current All Risks, Ltd. producer to submit applications. Consultants Liability Application Applicant s Name: Agency Name: Agent No.: Mailing
More informationFIREPLUS SUPPLEMENTAL APPLICATION
FIREPLUS SUPPLEMENTAL APPLICATION SECTION 1: GENERAL INFORMATION Applicant Name: Mailing Address: Street Address: Effective Date: Date Needed: Expiring Premium: $ Target Premium: $ Incumbent Carrier: Submitting
More informationCOMMERCIAL INLAND MARINE APPLICATION (Animal Floater, Golf Carts, Signs)
Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Scottsdale Indemnity Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Scottsdale Surplus Lines Insurance
More informationHOME INSPECTORS PROFESSIONAL LIABILITY INSURANCE APPLICATION THIS INSURANCE, IF ISSUED, WILL BE ON A CLAIMS-MADE AND REPORTED BASIS.
800 Oak Ridge Turnpike, Suite A-1000 Oak Ridge, Tennessee 37830 HOME INSPECTORS PROFESSIONAL LIABILITY INSURANCE APPLICATION THIS INSURANCE, IF ISSUED, WILL BE ON A CLAIMS-MADE AND REPORTED BASIS. NOTICE:
More informationAllied Healthcare Professional and General Liability Product
USLI.COM 888-523-5545 Allied Healthcare Professional and General Liability Product This is an application for a claims made (professional) and occurrence (general liability) policy. Please read your policy
More informationMOTORSPORTS OFF TRACK EQUIPMENT APPLICATION
MOTORSPORTS OFF TRACK EQUIPMENT APPLICATION SUBMISSION REQUIREMENTS Completed signed / dated Supplemental Applications Completed ACORD Applications (Property, Auto and Umbrella Liability) if coverages
More information