Insurance Special Event Application

INSURANCE SPECIAL EVENT APPLICATION

Application Date:

Applicant / Insured Information

Individual    Corporation    LLC    Nonprofit    Other

Event Details

Will alcohol be sold or served? Yes No

Security personnel contracted? Yes    If yes, number of guards:

Requested Coverage & Limits

Select coverage types and requested limits:

General Liability    Limit: $

Liquor Liability (if alcohol served)    Limit: $

Participant / Participant Legal Liability    Limit: $

Property Damage    Limit: $

Medical Payments    Limit: $

Cancellation / Non-Appearance Coverage    Limit: $

Exclusions & Conditions (Representative)

The policy, if issued, will be subject to standard terms, conditions and exclusions. Applicant acknowledges that coverage is likely to exclude or limit losses arising from the following (unless specifically endorsed):

• Intentional acts, fraudulent acts, and unlawful conduct by insureds or their agents
• Claims arising from professional services or advice unless specifically endorsed
• Wear and tear, mechanical failure, and latent defects
• War, nuclear hazard, and similar perils
• Asbestos, mold, and pollution-related loss unless specifically endorsed
• Communicable disease exclusion may apply where applicable

Applicant acknowledges that the insurer may require additional underwriting information, site inspection, contracts with vendors, proof of permits and licenses, and executed security contracts prior to binding coverage. No coverage binds until insurer or authorized broker issues confirmation in writing.

Beneficiary / Certificate Holder

Documentation Checklist

Check all documents attached to this application:

Site plan / site map

Vendor / Contractor contracts

Alcohol permit (if applicable)

Security contract / guard roster

Venue contract / indemnification agreement

Declarations, Authorizations and Certification

By submitting this application, Applicant represents and warrants that the statements and facts contained herein are true, complete and accurate to the best of Applicant's knowledge. Applicant understands that material misstatements, omissions or fraudulent statements may result in denial of coverage, rescission of any policy issued, or voidance of coverage for the event.

Applicant authorizes the insurer and its representatives to obtain and verify information concerning any statement contained in this application, including but not limited to prior loss history, criminal history related to operations, vendor contracts, and permit status. Applicant agrees to cooperate with reasonable underwriting inquiries and inspections.

Applicant agrees to defend, indemnify and hold harmless the insurer and any certificate holder for acts or omissions by Applicant or its agents which are outside the scope of the policy or which violate applicable law, venue rules, permits or contractual obligations. Applicant further agrees that coverage, if issued, will be governed by the policy form and endorsements issued and not by representations in this application except to the extent expressly stated in a binder or policy declaration.

Fraud Warning: Any person who knowingly presents a false or fraudulent claim or application for insurance may be subject to civil and criminal penalties under applicable law.

Additional Information / Notes

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