Special Event Application

Foreign Special Event Application

For Single Events
Click here for Insurance Terms & Definitions.
APPLICANT INFORMATION
How did you hear about us?*
Select how you found our website.
What coverages do you require?*

General Liability (Required)Rented/Owned EquipmentContingent Auto Coverage
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:*

UNDERWRITING QUALIFICATION QUESTIONS
Any event with bounce houses or inflatables?*

YesNo
Do any events include any of the following: Stunts, Pyrotechnics, Aircrafts, Car Races, Precision Driving, Mechanical Amusement Devices, Film Production, or other Hazardous Activities?*

YesNo
Please explain:*

Insurance History
Any insurance declined or canceled in the past 3 years (not applicable in MO)?*

YesNo
Please explain:*
Any Prior Insurance Coverage?*

YesNo
If yes, please provide details below:*
Policy type, Carrier, Policy Number, Expiration Date, & Premium Paid
Any losses in the past 3 years?*

YesNo
If yes, please provide details below:*
Policy Type, Date of loss, Description of loss, & Amount of loss.

EVENT DETAILS
Event Start Date*

MonthDayYear
Date
Event End Date*

MonthDayYear
Insurance exp. is 12:01am. If your last day or filming is April 25th use April 26th as the last day of coverage (as it will expire on 04.26 12:01am).
Event Name*
Event Description*
Venue Name:*
Venue Address:*
Event Website URL
Cost/Budget*
Any Live Music/Concerts?*

YesNo
Please Provide the Name Of the Artist(s)/Band(s)*
Any Celebrities At The Event?*

YesNo
If yes, provide names:*
Event will be held:*

IndoorsOutdoorsBoth
Maximum Daily Attendance*
Total Attendance*
Number of Participants/Performers*

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:*
Per Occurrence
Liquor Liability:*

YesNo

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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Foreign Special Event Application