Allianz Global Corporate CONTACT & US Specialty 2350 W. Empire MAILING Avenue, ADDRESS Suite #200 4512 Burbank, CHURCH CA 91504 AVENUE BROOKLYN, NY 11203 TEl: 800-870-5190 PROMOTER AND FESTIVAL SUPPLEMENTAL APPLICATION FAX: 800-420-4190 admin@theinsurancegirl.co Name of Applicant: Date of Application: In business under present management since: If less than 3 years in business list all previous names under which you have operated as a promoter: Website: Single Event Only (bypass Multiple Events or Annual Promoter section below) Provide event description: Event Location: Event Dates including load in/out: From To Number of performance days: Admissions: Per day: Total All days: Location Type: Indoors or Outdoors Has this event been held before? If yes, please explain: Multiple Events or Annual Promoters Estimated Number Of: Annual admissions: Annual gross receipts: Annual performances: Annual admissions last year: Names of entertainers you promote: Facilities or venue used (include city and state): Do you have exclusive promotion rights at any venue(s)? If yes, please list venue names, city and state: Do you own any venue? If yes, please identify and explain: Do you provide talent buying services where you are not the promoter and are paid a fee? If yes, please include the number of annual shows and expected revenue: Please indicate the percentage of time you book in the following types of venues: Clubs % up to 500 % 500 to 1,000 % Over 1,000 Music Hall: % up to 1,000 % 1,000 to 5,000 % Over 5,000 Arenas: % up to 5,000 % 5,000 to 10,000 % Over 10,000 Stadiums: % up to 25,000 % 25,000to 50,000 % Over 50,000 Grandstands: % Open-air amphitheaters: % Open fields: % General Questions Do you require entertainers to provide evidence of insurance? Do you agree to hold harmless the entertainers while performing? Are you listed as an Additional Insured (AI) on their policy? Do you co-promote any events or shows? Do you enter into written contracts with these co-promoters? Do you receive a Certificate of Insurance (COI) naming you as an AI on the Co-Promoter s General Liability policy?
Type of seating used: Reserved seats General Admission Both Seating Construction: Permanent Temporary Seating Provided: Bleachers Stadium Folding Chairs Other: Type of concerts normally promoted (please indicate by percentage the type of music you plan to promote): % Alternative/Indie Rock % Children s % Church/Religious % Classical/ Easy Listening % Classic Rock % Comedy % Country/Bluegrass/Folk % Electronic/DJ % Heavy Metal/Grunge/Punk % Hip Hop/Rap % International/World % Jazz % Latin % Magician % Pop/Top 40 % R&B % Reggae % Rock & Roll % Sports: % Other: Security/Life Safety Who is providing security? (check all that apply) You Venue Contracted Service Police None If other than applicant, are there signed contracts outlining roles and responsibilities? Does the contract require the applicant to be held harmless? Minimum liability limits required? Is a Certificate of Insurance obtained confirming that the applicant is an Additional Insured on the provider s General Liability policy? If handled by employees, please explain any training program provided: Number of security personnel: Are weapons carried by you or a contract service? If weapons are carried by you or your employees, what type of training or certification is required? Identify any additional security/life safety measures: Emergency evacuation and communication plan in place? Evacuation/egress plan arranged with civil authorities? Weather Monitoring Closed Circuit Cameras Perimeter fencing (outdoor event only) Adequate drinking water available to attendees? (outdoor event only) Social Media Monitoring Walkway/Pathway Lighting Parking Area Patrolled Lighting Other: Fire Protection: Extinguishers Sprinklered Location Municipal Volunteer: Describe First Aid facilities: Who is responsible? City paramedic s Event staff Contracted Service If contracted service, are you listed as an Additional Insured on the contracted service s General Liability policy?
Are mosh pits, stage diving or body/crowd surfing allowed? If yes, please indicate the precautions and contingencies you put into place (select all that apply): Specified mosh pit area Security present in pit Restricted entry to pit Video Surveillance Explanation of rules Waiver/release from participants If no, what is your practice if mosh pits, stage diving or body/crowd surfing starts at an event? Are you a member of Event Safety Alliance or any other event safety association? Liquor Liability Will liquor be sold at the event(s)? Who is responsible for liquor sales (who holds the valid license)? If a third party is used, is a COI obtained evidencing liquor liability with you added as an AI? What limit of liquor liability does the third party carry? If a third party is used, do you receive a commission on the liquor sales? What controls are used? Wristband Other (describe) If you provide liquor, please complete liquor liability supplemental application. Additional Exposures Are there swimming pools, lakes or bodies of water as part of the event or within the applicant s contracted control? If yes: Will swimming be allowed? Will a certified lifeguard be present? Is water hazard fenced or patrolled? Do any events have overnight camping? Functional Responsibility Chart Applicant Subcontractor Venue N/A COI provided by Vendor Management of Facility Security (Armed or Unarmed) Liquor Sales Concessions Annual receipts and type of concessions: First Aid Pyrotechnics Special Effects Staging, Equipment, Rigging Tents Maintenance Amusement devices/rides Inflatable attraction Parking Merchandise Transportation Sanitation If you are not responsible, do you receive a COI listing the insured as additional insured including hold harmless provisions? Do you ever assume, by contract, the liability of other parties? If yes, explain
Required attachments: Copy of rental agreement or venue contract Copy of flyer, press release, advertising Facility diagram (outdoor events) Copies of COIs if applicant is responsible but subcontracts for security, rides, animals or pyrotechnics Loss Record for the last five (5) years Emergency Evacuation Plan (Festival only) Applicant Name: Agent/Broker: Signed By: Signed By: Signature: Signature: Title: Title: Date: Date:
FRAUD STATEMENT Important Information Please Read 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 and subjects such person to criminal and civil penalties (In Oregon, the aforementioned actions may constitute a fraudulent insurance act which may be a crime and may subject the person to penalties). (In New York, the civil penalty is not to exceed five thousand dollars ($5,000) and the stated value of the claim for each such violation). (Not applicable in AL, AR, AZ, CO, DC, FL, HI, ID, KS, LA, ME, MD, MN, NM, NJ, OH, OK, PR, RI, TN, UT, VA, VT, WA and WV per attached form 141874). APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment for a loss or benefit or who knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. APPLICABLE IN COLORADO: 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. APPLICABLE IN FLORIDA AND OKLAHOMA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (In FL, a person is guilty of a felony of the third degree). APPLICABLE IN HAWAII: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both: The absence of such a warning in any application or claim form shall not constitute a defense to a charge of insurance fraud under state law. APPLICABLE IN IDAHO: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement containing any false, incomplete, or misleading information is guilty of a felony. APPLICABLE IN KANSAS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. APPLICABLE IN MAINE, TENNESSEE, VIRGINIA 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 may include imprisonment, fines or a denial of insurance benefits. APPLICABLE IN MINNESOTA: A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. APPLICABLE IN NEW JERSEY: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. APPLICABLE IN OHIO: Any person who, with intent to defraud or knowingly 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. APPLICABLE IN UTAH (WORKERS COMPENSATION): Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison. APPLICABLE IN VERMONT: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.