lkalmanson - Circus Liability

AGENCY: LESTER KALMANSON AGENCY INC. &/OR MITCHEL KALMANSON

P.O. BOX 940008
MAITLAND, FLORIDA 32794-0008 - USA
PH:407-645-5000 / FAX. 407-645-2810 www.lkalmanson.com

I M P O R T A N T: THIS IS NOT A BINDER
INCOMPLETE AND UNSIGNED APPLICATIONS ARE NOT ACCEPTABLE.

PROPOSED EFFECTIVE DATE

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TERM

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NAMED INSURED

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DBA

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MAILING ADDRESS

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CITY

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STATE

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ZIP

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select

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IF OTHER

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PHYSICAL LOCATION(S) WHERE OPERATION(S) WILL TAKE PLACE

VARIOUS USA

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VARIOUS USA

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CANADA

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CANADA

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OTHER

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OTHER

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EXPLAIN

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PHONE

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FAX

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CELL

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EMAIL

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REQUESTED LIMITS OF LIABILITY (PER OCC. / AGG.)

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IF OTHER

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DESCRIPTION OF ALL CIRCUS EXPOSURE(S) &/OR OPERATION(S) &/OR ACTIVITY(S) TO BE INSURED

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ATTACH (MAIL / FAX) COPY(S) OF ANY AND ALL OF THE FOLLOWING

A) CONTRACTS, BROCHURES, PAMPHLETS, PROGRAMS, ALONG WITH SAFETY
MANUALS, SITE/SEATING PLANS, RECORDS, ETC.

B) LEASE AGREEMENT, HOLD HARMLESS AGREEMENTS BETWEEN YOU AND ANY
OTHER PARTY WITH REGARD TO THIS EVENT.

C) DIAGRAM AND PHOTOS OF LOCATION(S) / SET UP - IF AVAILABLE

PRIOR CARRIER INFORMATION (LAST THREE YEARS)

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COMPANY POLICY # POLICY PERIOD LIMITS PREMIUM(S)

A)

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B)

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C)

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LOSSES IN THE PAST FIVE (5) YEARS

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DATE DESCRIPTION AMT PAID AMT RESERVED

A)

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B)

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C)

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HAS ANY PRIOR COVERAGE(S) BEEN CANCELLED AND / OR NON-RENEWED

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IF YES, EXPLAIN

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PROVIDE LIST OF ADDITIONAL INSURED(S) TO BE INCLUDED / ADDED

(NOTE: SUBJECT TO ADDITIONAL PREMIUM)

1)

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2)

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3)

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**ATTACH SEPARATE LIST IF REQUIRED**

PROVIDE (MAIL/FAX) COPY OF EXPIRING PRICING, TERMS AND CONDITIONS

ATTACH (MAIL/FAX) PROPOSED (TENTATIVE) SCHEDULE OF EVENT(S) TO BE INSURED:

PROVIDE LIST OF EVENT / ACTS IN CIRCUS (IE: PERFORMERS / TALENT)

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CONCESSIONS

WHAT TYPE (EXPLAIN – LIST)

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WHO IS RESPONSIBLE FOR PROVIDING

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HOW MANY PEOPLE WILL BE USED

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WHAT IS SOLD &/OR SERVED

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ESTIMATED ANNUAL / TERM RECEIPTS FOR ALL CONCESSIONS

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PARKING: WHO IS RESPONSIBLE?: EXPLAIN

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SECURITY / USHERS

WHAT TYPE

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WHO IS RESPONSIBLE FOR PROVIDING

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HOW MANY (EST.) PEOPLE WILL BE USED

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ARE THEY EMPLOYEE(S) OR INDEPENDENT CONTRACTOR(S)

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ANIMAL RIDES OFFERED

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WHAT TYPE - EXPLAIN (IE: ELEPHANT / CAMEL / PONY / ETC.)

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select

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EXPLAIN

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ATTACH (MAIL / FAX) COPY OF INSURANCE LIABILITY CERTIFICATE FOR ALL CONTRACTED ANIMAL RIDE(S)

NO CONTRACTED ANIMAL RIDES

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ANY PHOTO OPPORTUNITIES WITH ANIMAL(S)

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IF YES, EXPLAIN

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ANIMAL ACTS USED IN SHOW

LIST WHO

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TYPE OF ANIMALS USED

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PROVIDE (MAIL / FAX) COPY OF INSURANCE CERTIFICATE FOR ALL CONTRACTED ANIMAL ACTS TO BE USED IN THE SHOW/CIRCUS

NO CONTRACTED ANIMAL ACTS

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INDICATE HOW EXOTIC ANIMAL(S) ARE BROUGHT INTO THE RING

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STATE WHERE SHOW(S) / CIRCUS IS/ARE TO BE SET UP

TENT

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FULL TENT DESCRIPTION

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WHO OWNS TENT

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SIZE OF TENT

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ESTIMATED NUMBER OF PEOPLE TENT WILL HOLD

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IS TENT PROPERLY FIRE RATED

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IS TENT INSPECTED BY LOCAL FIRE MARSHAL(S)

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OUTSIDE

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INSIDE BUILDING(S)

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OTHER – EXPLAIN

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DO YOU EMPLOY OR CONTRACT A TENT MASTER FOR SET-UP AND STRIKE DOWN OF THE TENT

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IF YES, NAME OF TENT MASTER

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IF YES, PROVIDE (MAIL / FAX) COPY OF CONTRACT AND CREDENTIALS OF TENT MASTER

INDICATE TOTAL (ESTIMATED) # OF

SHOWS PER YEAR / POLICY PERIOD

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PERFORMANCES / SHOWS PER DAY

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ESTIMATED NUMBER OF PERFORMANCES PER SHOW DAYS / PER POLICY PERIOD

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NUMBER OF UNITS

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AKA

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AKA

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OTHER

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GIVE ESTIMATE GROSS SHOW RECEIPTS (DO NOT INCLUDE CONCESSIONS)

SHOW DATE

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PER YEAR

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PER UNIT

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GIVE ESTIMATE GROSS CONCESSION RECEIPTS ONLY

A) SHOW DATE

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B) PER YEAR

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C) PER UNIT

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INDICATE TYPE OF SEATING USED PER LOCATION

WHO IS RESPONSIBLE FOR SET UP

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WHAT IS THE TOTAL CAPACITY PER EVENT LOCATION

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PROVIDE DESCRIPTION OF SEATING / BLEACHERS:

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HOW OFTEN IS SEATING CHECKED/INSPECTED

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IS ANY EQUIPMENT LEASED &/OR RENTED

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IF YES, EXPLAIN

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IS THE CIRCUS (PERIMETER) AREA COMPLETELY FENCED

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IS/ARE THE PATRONS / PUBLIC RESTRICTED FROM THE WORK / STAGING (GREEN) / ANIMAL AREAS

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ARE ALL “OFF LIMIT” AREAS WELL MARKED

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PROVIDE (MAIL/FAX) CERTIFICATE OF APPROVAL BY THE LOCAL FIRE DEPARTMENT

INFLATABLE(S): SPECIFICALLY EXCLUDED

[SEPARATE "INFLATABLES" APPLICATION WILL NEED TO BE COMPLETED FOR ANY / ALL INFLATABLE(S)]

ARE ALL SITES

PRE CLEARED

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PROPERLY INSPECTED FOR ANY UNDERGROUND UTILITIES BEFORE SET-UP IS ALLOWED

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IS ANY WORKER’S COMPENSATION / EMPLOYER’S LIABILITY COVERAGE REQUIRED

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IF YES, PROVIDE STATES

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IS ANY COMMERCIAL AUTO LIABILITY REQUIRED

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PROVIDE FULL DETAILS

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ANY PHYSICAL DAMAGE COVERAGE REQUIRED

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PROVIDE (MAIL/FAX) FULL INVENTORY / ITEMS TO BE INSURED

PROVIDE COPY(S) OF ANY & ALL CONTRACTS BETWEEN CIRCUS &/OR PERFORMERS WITH THE SCHEDULED VENUE.

PROVIDE COPY(S) OF ANY & ALL CONTRACTS BETWEEN CIRCUS AND CONTRACTED TALENT

REMARKS: (IF ANY)

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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 OF THE THIRD DEGREE.

I UNDERSTAND AND AGREE THAT ANY MISSTATEMENT OF WARRANTY OF FACT ON THIS APPLICATION
SHALL BE CONSIDERED A VIOLATION OF COVERAGE AFFORDED UNDER ANY POLICY ISSUED ON THE
BASIS OF THIS APPLICATION.

(THIS APPLICATION WILL BECOME PART OF ANY POLICY ISSUED AS A RESULT OF ITS SUBMISSION.)

THIS LIABILITY INSURANCE DOES NOT APPLY TO ANY "BODILY INJURY," &/OR "PERSONAL INJURY," &/OR
ANY MEDICAL PAYMENTS (IF AFFORDED) &/OR ANY LEGAL DEFENSES ARISING OUT OF ANY CLAIM(S),
ACCUSATION(S), &/OR CHARGE(S) BROUGHT BY AND/OR AGAINST ANY INJURED(S) FOR ACTUAL
AND/OR ALLEGED DAMAGE(S) AND/OR INJURIES ARSING OUT OF ANY COMMUNICABLE DISEASE(S)
&/OR INFECTION(S), INCLUDING E-COLI INFECTION &/OR BACTERIA, NO MATTER HOW TRANSMITTED, BY
ANY (NAMED) INSURED'S &/OR IT'S EMPLOYEES &/OR ANY OF THEIR ANIMAL/SPECIES, INCLUDING BUT
NOT LIMITED TO ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS) AND/OR ANY OTHER
COMMUNICABLE DISEASE(S) AND/OR INFECTION(S) AND/OR BACTERIA.

IT IS FURTHER AGREED AND UNDERSTOOD THAT THIS SPECIFIC COMMUNICABLE / INFECTIOUS
DISEASE EXCLUSION ENDORSEMENT WOULD APPLY TO ANY AND ALL CLAIMANT(S) WHETHER
INDIVIDUALLY AND/OR AS A CLASS MEMBER OF ANY CLASS ACTION LITIGATION

PLEASE INITIAL AND DATE TO ACCEPT TERMS OF APPLICATION (REQUIRED TO PROCESS APPLICATION)

INITIAL

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DATE

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AFTER SUBMITTING YOUR ONLINE APPLICATION

PLEASE DOWNLOAD, PRINT, AND SIGN THE "CIRCUS LIABILITY" AND "TERRORISM" SIGNATURE FORMS

THESE FORMS REQUIRE WET SIGNATURES AND MUST BE RECEIVED VIA MAIL TO PROCESS THE APPLICATION

***CONFIDENTIALITY NOTICE: This message and any attachments are for the sole use of the intended
recipient(s) and may contain confidential and privileged information that is exempt from any public disclosure.
Any unauthorized use, review, disclosure, or distribution is prohibited. If you have received this message in error, please
contact the sender by phone or electronic mail, and destroy all copies of this message.***

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CIRCUS / PERFORMANCE LIABILITY APPLICATION CLAIMS MADE POLICY FORM

AGENCY: LESTER KALMANSON AGENCY INC. &/OR MITCHEL KALMANSON

PLEASE INITIAL AND DATE TO ACCEPT TERMS OF APPLICATION (REQUIRED TO PROCESS APPLICATION)

AFTER SUBMITTING YOUR ONLINE APPLICATION

PLEASE DOWNLOAD, PRINT, AND SIGN THE "CIRCUS LIABILITY" AND "TERRORISM" SIGNATURE FORMS

THESE FORMS REQUIRE WET SIGNATURES AND MUST BE RECEIVED VIA MAIL TO PROCESS THE APPLICATION