Event Liability Application
1. Event Sponsor (Named Insured):
2. Mailing Address:
3. Phone: / Fax: / E-Mail:
4. Contact Name:
5. Event Location including address:
6. Event Duration:
/ Mo. Day Year / Mo. Day Year
/ to
7. Event Times:
/ From / a.m./p.m. / To / a.m./p.m.
8. Alternate Date (rain date) for event:
9. Event Description including all activities (only activities shown will be covered):
9a. If Event is a Wedding Ceremony, is coverage needed for Wedding Rehearsal the day before? / Yes / No
9b. If Event includes the Wedding Rehearsal, is coverage needed for the Rehearsal Dinner? / Yes / No
10. Estimated Gross Receipts for Event:
11. Estimated Attendance:
12. Number of Food/Beverage Vendors:
13. Number of Non Food/Beverage Vendors:
14. Number of Exhibitors (no sales of products):
/
Event Liability Application (continued)
15. Limit of Liability Required for this Event:
($1,000,000 is the base limit and maximum limit)
16. Has similar insurance been purchased in the past: Yes
/ No
If Yes, please advise name of prior insurance company:
Have any losses been incurred during the last 3 years under the type of coverage being
applied for herein, whether or not insured? Yes
/ No
If Yes, provide date of loss, description and amount of settlement:
17. / Certificates of Insurance - Please provide names and addresses of those requiring a certificate of insurance.
Name:
Address:
City: / State: / Zip Code:
Phone: / Fax: / E-Mail:
Additional Insured: Yes / No
If Yes, please provide reason:
Name:
Address:
City: / State: / Zip Code:
Phone: / Fax: / E-Mail:
Additional Insured: Yes / No
If Yes, please provide reason:
Name:
Address:
City: / State: / Zip Code:
Phone: / Fax: / E-Mail:
Additional Insured: Yes / No
If Yes, please provide reason:
Event Liability Application (continued)

If the event is a concert, complete questions 18-29. If not, skip to questions 30-36.

18. / Type of Concert: / Jazz/Blues / Pop/
Rock / Hard Rock / Country / Classical / Other
19. / Artists Performing:
20. / Indoors/Outdoors: / If outdoors, fenced or otherwise enclosed? / Yes / No
21. / Reserved Seating? / Yes / No / General Admission? / Yes / No
22, / Type of Seating: / Bleacher / Grandstand / Theater
Folding Chairs / Ushers Used? / Yes / No
23. / Is a venue management firm being used? / Who is supplying venue mgt.?
24. / Is applicant signing any hold harmless agreements? / If yes, with whom?
What responsibility is being assumed?
25. / Attach copies of all contracts/hold harmless agreements signed by applicant.
Who provides event security?
Are uniformed police officers on premises?
26. / Are there any other additional insured requirements other than the venue?
If yes, what are their interests in relation to the event?
27. / Has applicant held this type of event in the past?
28. / Any previous claims?
29. / Were past events covered by insurance?
Which insurance company?
Event Liability Application (continued)

If liquor is sold and liquor liability insurance is required, complete questions 30-36. If not, skip to signature section.

30. / Type of license: / Retail / Wholesale
31. / License #:
32. / Has your liquor license ever been non-renewed or revoked?
33. / Estimated receipts from the sale of alcoholic beverages:
34. / Any sales other than beer or wine? / Yes / No
35. / Have servers completed ASK (Alcohol Servers' Knowledge) Seminars? / Yes / No
36. / Provide details about controls in place to prevent sales to minors i.e. wristbands, stamps, tickets, restricted areas.

Application must be signed and dated.

Fax or mail application to Cover Events for quotation.

Payment by check required 10 days prior to event date. Make check payable to: LMC Insurance & Risk Management

Fax: 515-244-9535 Mailing Address: 4200 University Avenue, Ste 200

West Des Moines, IA 50266-5945

Phone: 1-800-677-1529

Warranty

The applicant, by signing this application, declares that the statements set forth herein are true. Signing the application does not bind the applicant or the insurance company. Coverage cannot be bound without payment and application being received 10 days prior to start date of the event. Fraud or misrepresentation of information on this application may void the insurance contract. Cover Event personnel reserve the right to visit the event to assure accuracy of statements on this application.

Signed (applicant) ______

Name (print) ______

Title (print) ______

Date ______