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 Box 749, South Bend IN 46624-0749 2. Mailing Address Street City County State ZIP Code 3. Effective Date Desired Term Desired 4 COVERAGES LIMITS Products-Completed Operations General Aggregate $ Premises Operations Products-Completed Operations Aggregate $ Medical Payments Personal and Advertising Injury Limit $ Contractual Liability Each Occurrence Limit $ Damage to Premises Rented to You Damage to Premises Rented to You Limit $ Personal and Advertising Injury Medical Expense Limit $ 5. PRIOR INSURANCE CARRIER AND LOSS HISTORY FOR THE PAST THREE YEARS Year Carrier/Policy Number/ Premium Coverage Losses Amount Description of Losses (Use separate sheet if necessary Missouri Applicants: DO NOT answer this question. Has insurance of this type been cancelled, refused, or non-renewed by any company during the past 3 years? No Yes - If so, give name of company, date, and reason. UNDERWRITING INFORMATION 6. Additional Insured(s) required? Yes No Provide name and describe interest. 7. Location of Primary Event Street City County State ZIP Code 8. Provide a complete description of all events including locations and dates (Attach brochures or any other advertising) 9. If applicable, hours of event: From To 10. Will first aid services be available? Yes No 11. Will alcohol be served? Yes No 12. Are there mechanical rides, moonwalks, trampolines, dunk tanks or water slides? Yes No 13. Describe security and crowd control measures. S62-CG (11/01) Page 1 of 3
14. Are any water hazards present? Yes No If yes, explain. 15. Will fireworks be displayed? Yes No If yes, would you like coverage as a sponsor of the fireworks? Yes No If yes, who will be igniting the fireworks? Fire Department Licensed Pyrotechnist Other (Explain in detail) Igniter is an: Employee Independent contractor (Attach certificate of insurance for the part responsible for igniting the fireworks.) 16. Number of grandstands or bleachers (If any) Permanent Temporary 17. Seating capacity Are all seats assigned? Yes No N/A 18. Estimated attendance per day Ticket price Est. gross receipts 19. Is contractual liability required? Yes No If Yes, describe all contracts and/or hold harmless agreements, whether written or oral (including dates, contracting parties, and cost). 20. Is set up and take down coverage desired? Yes No If Yes, on what date(s)? 21. How many times has this event been held in the past? 22. Do you use independent contractors? Yes No If Yes, describe how. 23. Are certificates of insurance secured from exhibitors and vendors? Yes No 24. Describe any products sold by or for the Named Insured. CONCERTS ONLY 1. Location of concert(s) Date(s) 2. Estimated attendance for the concert(s) only 3. Seating is: Assigned Unassigned Capacity of facility used for concert: 4. Type of music being performed: Country Pop (Top 40) Rap Hard Rock Punk Classical East Listening Other 5. List all performances or groups. S62-CG (11/01) Page 2 of 3
IMPORTANT NOTICE I DECLARE THAT THE STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND TRUE. Any person who, with the intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud and subject to fines and/or imprisonment. As part of our underwriting procedures, a routine inquiry may be made to obtain applicable information concerning character, general reputation, and credit history. Upon your written request, additional information as to the nature and scope of the report, if one is made, will be provided. Signature of Applicant Title Date Signature of Producing Agent Date Agent Name and Address S62-CG (11/01) Page 3 of 3
RACING SPECIAL EVENTS SUPPLEMENTAL APPLICATION (Complete in addition to Special Events Application) 1. Named Insured: 2. Track Name: 3. Promoter s and/or Sponsor s Name: 4. Type of Race(s) (i.e., Stock Cars, Sprint or Midget, Motorcycles, ATVs, 4 Wheelers, Tractors, Trucks, Semi-Trucks, Snowmobiles, etc.): 5. Number of Event dates planned for current year: Number of Events held last year: 6. Annual Receipts: $ 7. Average attendance per Event date: Maximum attendance per Event date: 8. Track Description: A. Attach diagram showing the following: 1. Location of all grandstands/bleachers and any other area where spectators are allowed; 2. Pit area location including entrance and exits; 3. Location of debris fence and barriers; 4. Location of designated parking areas; 5. Location of all concessions, rest rooms, medical facilities, etc.; 6. Location of crowd control fences; and 7. Shape of track (straight, oval, serpentine, etc.). B. Length of track: C. Track surface (dirt, concrete, asphalt, other): 9. Barriers: Construction type/material: Height: Thickness: How many feet from the lowest set of seats or spectator area to the barrier? Does barrier protect: Pit Area?... Yes No Spectator Areas?... Yes No Private Property?... Yes No GLS-APP-62s (11-06) Page 1 of 2
10. Debris Fence: Fence post material (wood, concrete, metal): Number of feet between fence posts: Height above racing surface: Type/gauge of fence wire: Does debris fence protect all Spectator Areas?... Yes No 11. Seating: Grandstand or bleacher seating capacity: Grandstand/bleacher construction material: Age: Are spectators permitted to sit in: Their autos to watch the race?... Yes No The infield?... Yes No The pit area?... Yes No Are there grandstands in the pit area?... Yes No Are the grandstands in the pit area protected by a barrier?... Yes No 12. Are there any playground/amusement rides on the premises?... Yes No 13. Is there a medical or first aid facility on the premises?... Yes No 14. Does the applicant have a Web site?... Yes No If Yes, provide the Web site address: 15. Contact Person: Phone Number: FRAUD WARNING: 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. FRAUD WARNING (APPLICABLE IN TENNESSEE AND WASHINGTON): 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 WARNING APPLICABLE IN THE STATE OF NEW YORK: 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. APPLICANT S NAME AND TITLE: APPLICANT S SIGNATURE: (Must be signed by an owner, partner or executive officer) PRODUCER S SIGNATURE: DATE: DATE: GLS-APP-62s (11-06) Page 2 of 2