Annual Event Application

Annual Event Application

For Multiple Events over a 12 month period.
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APPLICANT INFORMATION
How did you hear about us?*
Select how you found our website.
What coverages do you require?*

General Liability (Required)Rented EquipmentAuto CoverageWorkers Compensation
Insured Name*
The name of your production company or entity (or individual name if not incorporated) you would like to insure. Use the same name as on your rental quote.
Entity Type*
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*

Confirmation Email
Website
Description of your operations:*

Event Schedule

	Name of Event	Start Date	End Date	Budget	Type of Event	Estimated Number of Attendees
Event 1
Event 2
Event 3
Event 4

Will you have more then 4 events under this policy?*

YesNo
If you will have more than 4 events under this policy you may have to submit a more detailed schedual to the broker.

General Liability

General Liability covers payments the insured will become legally obligated to pay as a result of Bodily Injury or Property Damage arising out of an occurrence during live events, performances, etc. Applies to third parties, excluding your own cast and crew, location. Injury to your own cast and crew can be covered under workers compensation, if selected. If you would like a quote with workers compensation a separate application is be required.
Please select a General Liability limit:*
Damage To Rented Premises*
Do you require a waiver of subrogation?*

YesNo
Who is requiring the waiver?*
What is their involvement in the event?*

Rented Equipment
Rented Equipment Replacement Value:*
What type of equipment is being rented?*
Will the property be stored overnight?*

YesNo
Please provide details on how it will be stored:*
Will the Insured be responsible for transporting the property?*

YesNo
How will it be protected from damage during transport?*
Who is transporting the property?*
Is the company transporting the property naming the Insured as Additional Insured on their Insurance policy?*

YesNo
Will the property stay in the possession of the Insured at all times prior to returning to rental company?*

YesNo
Please explain:*
Which equipment rental houses are you using?*

Workers Compensation

Covers medical injury to your hired cast or crew. This may include W2 employees, 1099 freelancers & volunteers. Available in most states.
Worker’s Comp limit of $1,000,000*

IncludeExclude
Waiver of Subrogation

IncludeExclude

Name & address of the entity which will require the waiver:

	Name	Street Address	City	State	Zip Code
Entity #1
Entity #2

	Part Time	Full Time
Number of Employees

Additional Information, Comments
Additional Information or Comments, if necessary, can be provided.
Would you like to receive our quarterly newsletter?*

YesNo
NY License # BR-1001302

CA License # 0I36156 - dba in CA as New York Film Emporium Insurance Services
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