“On Time & Under Budget!”

ANNUAL EVENTS APPLICATION

APPLICANT INFORMATION

1. / Insured name:
2. / Entity Type: / LLC LLP Corp. Individual Non-Profit Other
3. / Primary Address:
(No PO Boxes)
City: / State: / Zip code:
4. / Mailing Address
(if different from primary):
City: / State: / Zip code:
5. / Contact name:
6. / Phone #: / Alternate phone #: / Fax #:
7. / E-mail address:
8. / Website:
9. / Federal ID #: / OR Social Security #:
10. / Description of business operations:

UNDERWRITING QUALIFICATION QUESTIONS

11. / Any private armed security (i.e. armed security that work exclusively for you under your employ)? / Yes No
12. / Anyevent with bounce houses or inflatables (If yes, certificates of insurance are required)? / Yes No
13. / Do any events include any of the following: Stunts, Pyrotechnics, Aircrafts, Car Races, Precision Driving, Mechanical Amusement Devices, Film Production, Live Rap/Hip-Hop or Metal Music Performances, or other Hazardous Activities? / Yes No
If yes, please explain:

INSURANCE HISTORY

14. / Any insurance declined or cancelled in the past 3 years (not applicable in MO)? / Yes No
If yes, please explain:
15. / Any Prior Insurance Coverage? / Yes No
If yes, please provide details below:
Policy type / Carrier / Policy # / Expiration date / Premium paid
$
$
16. / Any losses in the past 3 years? / Yes No
If yes, please provide details below:
Policy type / Date of loss / Description of loss / Amount of loss
$
$

DATES OF COVERAGE

17. / Effective date:

INLAND MARINE

Indicate total replacement value for each desired coverage

18. / Rented Equipment (equipment of others) / $
19. / Third Party Property Damage: / $

OWNED EQUIPMENT

20. / Theatrical Property: / $ / Scheduled (replacement cost) Unscheduled (ACV)
21. / Musical Instruments: / $ / Scheduled (replacement cost) Unscheduled (ACV)
22. / PA/Sound Reinforcement Equipment: / $ / Scheduled (replacement cost) Unscheduled (ACV)

COVERAGE ENHANCEMENTS

23. / Accounts Receivable: / $
24. / Business Personal Property: / $
25. / Computers: / $
26. / Extra Expense: / $
27. / Newly Acquired Property (Any one item/All items combined) / $25,000/$50,000 Exclude
28. / Property Rented or Leased to Others / $
29. / Rental Reimbursement / $
30. / Valuable Records Research / $

GENERAL LIABILITY

31. / General Liability limit: / $1,000,000/$2,000,000
32. / Blanket Additional Insureds/Certificates of Insurance: / Included
33. / Waiver of Subrogation: / Include Exclude
34. / Required Number of Waivers:
35. / Liquor Liability: / Include Exclude
36. / Liquor Sales: / $

AUTO

37. / Hired & Non-Owned Auto Liability: / Include Exclude
38. / Cost of Hire: / $
39. / Number of Loaned or Donated Vehicles:
40. / Number of days:
41. / Hired & Non-Owned Auto Physical Damage: / Please select:Exclude$125,000/$2,000,000

EXCESS LIABILITY

42. / Occurrence / Aggregate Limit:
(The excess liability is an additional layer of coverage above the general liability, auto, and employers liability.) / Please select:Exclude$1,000,000$2,000,000$3,000,000$4,000,000$5,000,000

SPECTATORS & PARTICIPANTS MEDICAL

43. / Coverage for Spectators: / Include Exclude
44. / Coverage for Participants: / Include Exclude
45. / Accidental Medical Benefit (Death/Dismemberment/Medical) / Please Select:Exclude$25,000/$25,000/$25,000$25,000/$25,000/$50,000$50,000/$50,000/$50,000

WORKER’S COMPENSATION (not available in all states)

46. / Worker’s Comp limit of $1,000,000: / Include Exclude
47. / Waiver of Subrogation: / Include Exclude
48. / Name of Payroll Company (if any):
49. / Name of company officer excluded from coverage: / Title: / Please select:CEOCFOOwnerPartnerSecretaryTreasurer
50. / Enter the number of employees & total payroll amount for each class of employee:
Class / # of full time employees*
(more than 20 hrs./week) / # of part time employees*
(less than 20 hrs./week) / Total Payroll*
Outside Salespersons / $
Clerical Office Employees / $
Motion Picture Production / $
Players or Musicians / $
All Other Employees / $

* - Include figures for all W2, 1099 & volunteer workers

IN ADDITION TO THIS APPLICATION, A VENUE SUPPLIMENTAL FORM MUST BE SUBMITTED FOR EACH SCHEDULED EVENT

Film Emporium, Inc.

1890 Palmer Ave., Ste. 403Larchmont, NY 10538

Tel: (212) 683-2433 / (800) 371-2555

Fax: (914) 833-2430