SPECIAL EVENTS LIABILITY APPLICATION

Name of Insured:
Address:
Broker:	Effective Date: to
Event (Full Description):
Event Location:
Revenue:
Prize Offer, if applicable: (Include Value)
Are there activities that will involve bouncy castles, trampolines, or water sports? Yes No
Live Music: Yes No	Description:
Food Served: Yes No	Description:
Alcohol Served: Yes No	Description:
If a third party is responsible for liquor, is there a legal liability policy in force and a certificate of insurance issued; with the applicant as the additional named insured? Yes No
Full description of activities:
Bleachers or Grandstands used?
Are there safety measures in place for: parking, security, trampolines, first aid, and/or supervision? Describe:
Coverage Limits:	$1,000,000	$2,000,000	$5,000,000
Previous Insurance:
Name of Previous Carrier:	Previous Policy #:
Have there been any losses or claims by the applicant in the past 5 years? If yes, complete below: No Yes
Date of Loss	Location #	Cause	Paid Amount	Insurance Company	Policy #

Signature of Insured: _______________________________________ Date: ___________________________