lkalmanson - Special Event

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

PO BOX 940008
MAITLAND, FL 32794-0008 U.S.A.
PHONE: 407-645-5000
FAX: 407-645-2810
WWW.LKALMANSON.COM

IMPORTANT: THIS IS NOT A BINDER

INCOMPLETE & UNSIGNED APPLICATIONS ARE NOT ACCEPTABLE

GENERAL INFORMATION

NAME OF INSURED

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PHONE NUMBER

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FAX NUMBER

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CELL NUMBER

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EMAIL ADDRESS

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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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STREET ADDRESS

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CITY:

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STATE

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ZIP

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PROPOSED EFFECTIVE DATE: FROM

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TO

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TERM

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YEARS IN BUSINESS

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DATE OF INCEPTION

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RETRO DATE

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RETRO DATE

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APPLICANT IS

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IF OTHER

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LIMITS OF LIABILITY REQUESTED

REQUESTED LIMITS OF LIABILITY [PER OCCURENCE / AGGREGATE]

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IF OTHER

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PROPOSED DEDUCTIBLE [PER CLAIM B.I./P.D.]

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IF OTHER

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III. EVENT INFORMATION

TYPE OF EVENT

BEER GARDEN / BEER TENT

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CONCERT / MUSICAL PERFORMANCE

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CONVENTIONS / TRADE SHOW / EXHIBIT

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MOTOR VEHICLE RACE / SHOW

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INDIVIDUAL VENDOR BOOTH

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SPORTING EVENT / TOURNAMENT

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WEDDING / WEDDING RECEPTION

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CAR SHOW

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GUN SHOW

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FUND RAISER

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FESTIVAL

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PARADE

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PARTY / SOCIAL EVENT

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PICNIC

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OTHER

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OTHER

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DESCRIBE APPLICANT'S ROLE AND RESPONSIBILITY IN EVENT

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IS THERE A WEBSITE FOR THIS EVENT

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IF YES, WEBSITE ADDRESS

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NAME OF ADDITIONAL INSURED

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A. MAILING ADDRESS

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ADDITIONAL INSURED'S INTEREST IN EVENT

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LOCATION OF EVENT

COMPLETE STREET ADDRESS, CITY, STATE, ZIP

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WILL EVENT TAKE PLACE ON THE APPLICANT'S PREMISES

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LOCATION IS

PRIVATE RESIDENCE

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CONVENTION CENTER

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ARENA

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LIQUOR-LICENSED ESTABLISHMENT

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STADIUM

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FAIR GROUNDS

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INDOORS

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OUTDOORS

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OTHER

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OTHER

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IS THE EVENT LOCATED IN A JURISDICTION WHICH PERMITS CIVIL CASES TO BE HEARD IN A TRIBAL COURT

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DATES OF EVENT: FROM

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TO

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(IF ONE DAY EVENT, END DATE SHOULD BE THE SAME AS START DATE. QUOTE WILL CONTEMPLATE COVERAGE FOR EVENTS CONTINUING PAST 12:00AM)

DESIRED COVERAGE DATES: FROM

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TO

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IF EVENT DATE(S) DIFFER(S) FROM DESIRED COVERAGE DATE(S), EXPLAIN

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IS SET-UP AND TAKE-DOWN COVERAGE NEEDED FOR ADDITIONAL DATES

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IF YES, WHAT ARE THE DATES AND WHAT WILL THIS EXPOSURE INCLUDE

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WILL THERE BE ANY HEAVY MACHINERY USED

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WOULD YOU LIKE TO INCLUDE A RAIN DATE

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IF YES, WHAT DATE

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HOURS OF EVENT: FROM

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HOURS OF EVENT: FROM

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TO

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TO

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IF HOURS VARY BY DATE, DESCRIBE

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FULL SCHEDULE / DESCRIPTION AND PURPOSE OF EVENT (Attach - Mail / Fax - copy of brochure, website pages, and flyer to this application &/or include details on all activities taking place):

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WILL THERE BE ANY ENTERTAINMENT

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IF YES, DESCRIBE AND INCLUDE NAME OF PERFORMERS AND ACTS:

A)

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B)

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C)

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D)

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E)

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ATTENDEES

ESTIMATED TOTAL ATTENDEES PER DAY

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AVERAGE AGE OF ATTENDEES

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IF APPLICANT IS AN INDIVIDUAL EXHIBITOR / VENDOR, WHAT IS THE ESTIMATED ATTENDEES PER DAY ANTICIPATED TO VISIT THEIR BOOTH?

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WHAT IS THE MAXIMUM CAPACITY OF THE FACILITY HOLDING THE EVENT

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COVERAGE DESIRED

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HISTORY

NUMBER OF YEARS EVENT HAS BEEN PREVIOUSLY HELD

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ACTUAL TOTAL ATTENDANCE FOR PRIOR YEAR'S EVENT

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PREVIOUS CARRIER

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POLICY NUMBER

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PREMIUM

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LOSSES OR CLAIMS DURING THE PAST FIVE YEARS

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IF YES, EXPLAIN

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LIQUOR LIABILITY

ESTIMATED NUMBER OF ATTENDEES CONSUMING ALCOHOL DAILY

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IS APPLICANT THE SOLE VENDOR / SERVER OF ALCOHOL AT EVENT

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IF NO, LIST THE NUMBER OF OTHER VENDORS/SERVERS SERVING ALCOHOL

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ARE ALL PARTICIPATING ALCOHOL VENDORS/SERVERS REQUIRED TO CARRY LIQUOR LIABILITY LIMITS FOR THIS EVENT

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IF YES, WHAT IS THE MINIMUM REQUIREMENT

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WILL ALCOHOL BE DISPENSED BY A PROFESSIONAL BARTENDER

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IF NO, DESCRIBE HOW AND BY WHOM ALCOHOL WILL BE DISPENSED

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DESCRIBE TRAINING AND/OR EXPERIENCE OF PERSONS SERVING ALCOHOL:

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WHAT MEASURES ARE IN PLACE TO PREVENT SERVICE OF ALCOHOL TO MINOR AND/OR INTOXICATED PERSONS

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IF REQUIRED, DOES APPLICANT HAVE A VALID LIQUOR LICENSE

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IS THE APPLICANT IN THE BUSINESS OF SELLING, SERVING, OR FURNISHING ALCOHOLIC BEVERAGES

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WILL ALCOHOL BE SOLD

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IS YES, ESTIMATED GROSS ALCOHOL RECEIPTS PER DAY

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IS "BYOB" (Bring Your Own Bottle) OR SELF-SERVICE OF ALCOHOL PERMITTED

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COMMERCIAL GENERAL LIABILITY

WILL EVENT FEATURE ANY OF THE FOLLOWING

MECHANICAL RIDES / DEVICES

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MOON BOUNCE, ROCK CLIMBING WALL, TRAMPOLINES, OR SIMILAR REBOUNDING DEVICE

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IF YES, DESCRIBE

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IF YES, WILL A CERTIFICATE OF INSURANCE BE OBTAINED FOR THIS EXPOSURE AT THE EVENT

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PETTING ZOO OR ANIMAL RIDES

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IF YES, WILL A CERTIFICATE OF INSURANCE BE OBTAINED FOR THIS EXPOSURE AT THE EVENT

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FIREARMS OR FIREWORKS

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OVERNIGHT CAMPING

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DUNK TANKS

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WATER HAZARDS

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IF YES, DESCRIBE

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WILL ATTENDEES BE PERMITTED TO SWIM, BOAT, JET SKI, OR FISH

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IF YES, DESCRIBE

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WILL THE EVENT USE EXHIBITORS, VENDORS, PERFORMERS, CONTRACTORS, SUB-CONTRACTORS, OR INDEPENDENT CONTRACTORS?

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IF YES, EXPLAIN

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ARE THEY REQUIRED TO CARRY THEIR OWN INSURANCE

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WHAT LIMIT IS REQUIRED

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DESCRIBE SECURITY MEASURES

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IS SECURITY PROVIDED BY

INDEPENDENT CONTRACTORS

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EMPLOYEES OF APPLICANTS

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ON-DUTY POLICE

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IF SECURITY IS PROVIDED BY INDEPENDENT CONTRACTORS, ARE THEY REQUIRED TO CARRY THEIR OWN INSURANCE

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IF THIS IS A "CONCERT / MUSICAL EVENT," COMPLETE THE FOLLOWING: (NOTE: COVERAGE FOR INJURY TO PERFORMERS AND ENTERTAINERS IS EXCLUDED FROM OUR POLICY)

NAME(S) OF PERFORMER(S)

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DESCRIBE TYPE OF MUSIC

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PERFORMERS ARE

LOCAL

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NATIONAL

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INTERNATIONAL

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WILL PYROTECHNICS BE FEATURED

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ANY SPECIAL EFFECTS

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IF YES, DESCRIBE

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IF THIS IS A "PARADE EVENT," COMPLETE THE FOLLOWING: (NOTE: COVERAGE FOR INJURY TO PARADE PARTICIPANTS IS EXCLUDED FROM OUR POLICY)

HAS PARADE ROUTE BEEN APPROVED BY LOCAL AUTHORITIES

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IF NO, EXPLAIN

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WILL PARADE ROUTE BE SECURED BY POLICE

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IF NO, EXPLAIN

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ARE PARADE PARTICIPANTS PERMITTED TO THROW SOUVENIRS, CANDY, OR OTHER ITEMS INTO THE CROWD

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DESCRIBE PARADE ROUTE FROM START TO FINISH

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IF THIS IS A "ATHLETIC EVENT," COMPLETE THE FOLLOWING: (NOTE: COVERAGE FOR INJURY TO ATHLETIC PARTICIPANTS IS EXCLUDED FROM OUR POLICY)

DESCRIBE ATHLETIC EVENT

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IS THIS EVENT

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IS ATHLETIC PARTICIPANT'S COVERAGE DESIRED

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IF THIS IS A "MOTOR VEHICLE RACE, RODEO, TRACTOR PULL, OR TRUCK SHOW," COMPLETE THE FOLLOWING: (NOTE: COVERAGE FOR INJURY TO PARTICIPANTS IS EXCLUDED FROM OUR POLICY)

IS THE VENUE DESIGNED SPECIFICALLY FOR THIS TYPE OF ACTIVITY

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ARE METAL OR CONCRATE BARRIERS IN PLACE TO ENSURE SPECTATOR SAFETY

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IF NO, DESCRIBE

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ARE BARRIERS PERMANENT

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HOW HIGH ARE BARRIERS

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WHAT IS THE DISTANCE BETWEEN THE BARRIERS AND SPECTATORS

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WILL THE VENUE PROVIDE A CATCH FENCE FOR THE EVENT

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ARE SPECTATORS EVER PERMITTED IN THE PIT OR INFIELD AREA

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WILL THE EVENT FEATURE AUDIENCE PARTICIPATION? (IE CALF SCRAMBLES, ETC)

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IF THIS IS A RODEO, ARE THE TRANSFER AREAS BETWEEN ANIMAL PENS AND THE COMPETITION RESTRICTED FROM THE GENERAL PUBLIC

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IF THIS IS A "HEALTH FAIR / CONVENTION," COMPLETE THE FOLLOWING:

WILL THE EVENT FEATURE ANY MEDICAL OR HEALTH TREATMENT

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IF THIS IS A "CAR SHOW / MOTOR VEHICLE SHOW," COMPLETE THE FOLLOWING: (NOTE: COVERAGE FOR INJURY TO PARTICIPANTS IS EXCLUDED FROM OUR POLICY)

DO VEHICLES REMAIN STATIONARY THROUGHOUT THE SHOW WITH THE ENGINES OFF

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WILL THE EVENT FEATURE BURNOUTS, DRAG RACES, OR FLAME THROWING

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REMARKS (IF ANY)

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I HEREBY APPLY TO LESTER KALMANSON AGENCY, INC FOR A POLICY OF INSURANCE AS SET FORTH IN THIS APPLICATION ON THE BASIS OF STATEMENT CONTAINED HEREIN.

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.)

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.

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

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 "SPECIAL EVENT" AND "TERRORISM" SIGNATURE FORMS

BOTH 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.***

captcha(*)

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Special Event Liability Insurance 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 "SPECIAL EVENT" AND "TERRORISM" SIGNATURE FORMS

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