SPECIAL EVENT APPLICATION - Surplus Ins

1 S62-CG (9/12) 2012 The Travelers Indemnity Company. All rights reserved. Page 1 of 6 First Named Insured & Other Named Insured(s) Address StreetCityCountyStateZIP AddressStreetCityCountyStateZIP :Fax: Website: :Contact person/phone #: Accounting/Records: Type: Individual Partnership Corporation LLC Trust Other (specify): Date Desired: From:To: Term Desired: PREVIOUS INSURER & LOSS HISTORY Attach separate sheet if necessary See Loss Runs Attached Missouri Applicants:DO NOT answer this question. Has insurance of this type been cancelled, refused, or nonrenewed by any company during the past 3 years? NoYes - If Yes, give name of company, date, and reason: Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give rise to claims for the past 3 years.

2 Policy DatesCarrierPolicy Number PremiumCoverage Check if Claims-MadeDescription of Loss COVERAGESLIMITS Products-Completed Operations General Aggregate $ Premises Operations Products-Completed Operations Aggregate $ Medical Payments Personal and Advertising Injury Limit $ Contractual Liability Each Occurrence Limit $ Damage to Premises Rented to You Damage to Premises Rented to You Limit $ Personal and Advertising Injury Medical Expense Limit $ UNDERWRITING INFORMATION of Primary EVENT StreetCityCountyStateZIP a complete description of all events including locations and of EVENT (if applicable): From:To: of setup and/or take down coverage needed?

3 Yes No If yes, provide your experience in conducting/hosting events of this or similar nature: SPECIAL EVENT APPLICATIONS62-CG (9/12) 2012 The Travelers Indemnity Company. All rights reserved. Page 2 of 6 7. Estimated attendance per day: Ticket price: $ Estimated Gross Receipts: $ contractual liability required? If yes, describe all contracts and/or hold harmless agreements, whether written or oral (including dates, contracting parties, and cost): Yes No certificates of insurance secured from exhibitors and vendors? Do you use independent contractors? If yes, describe: 11. Are there any playground/amusement rides on the premises?

4 If yes, provide details: 12. Is there an overnight exposure? If yes, provide details: EVENT of a politically sensitive nature? Will this EVENT be hosting any Air Shows? Will any ballooning, including hot air balloons or sky diving events be held? Will the EVENT include any gun related demonstrations/activities? 17. Describe any products sold by or for you: 18. Are any water hazards present? If yes, explain: First Aid 1. Will first aid services be available? Yes No If yes, explain: If yes, indicate who will be in charge of the facilities: Doctors Nurses Other: food and beverages sold or served by you? Will alcohol be served?

5 If yes, explain: Yes No Receipts: Food: $ Alcohol: $ 3. Is liquor sold or served by others? If yes, do they have their own insurance? Traffic Control/Security 1. Describe security and crowd control arrangements: of Security Employed # Armed # Unarmed Employed Security Independent Security Company Chaperons 3. Ratio of guards to admissions/spectators: they have power of arrest? Is there a written emergency plan in the EVENT of an accident? If independent security, are certificates of insurance furnished with Additional Insured status? Yes No 7.

6 Indicate who is responsible for crowd and traffic control: S62-CG (9/12) 2012 The Travelers Indemnity Company. All rights reserved. Page 3 of 6 Yes No 8. Is the parking concession owned or operated by you? a. If no, is the concession operated by others? b. Do they have their own insurance? 9. Area of public/vendor parking : Fireworks fireworks be displayed? If yes: a. Would you like coverage as a sponsor of the fireworks? b. Indicate who will be igniting the fireworks: Fire Department Licensed Pyrotechnist Other (explain in detail): Yes No 2. Igniter is an: Employee Independent Contractor Attach certificate of insurance for the party responsible for igniting the fireworks.

7 Policy limits on the Igniter s policy: 3. Distance between fireworks staging area and audience: spectators allowed in fireworks staging area? Are volunteers used to perform any duties? 6. Describe Public Fire & Safety Protection: Seating/Stadiums1. Number of grandstands or bleachers (if any): Permanent Temporary/Portable If portable, indicate who erects: they have their own insurance? If yes, will you be obtaining Certificates of Insurance? Are back and side railings provided? Yes No 4. Construction: Wood Steel Concrete Other: 5. Height (in feet): Age of bleachers or platforms: 6.

8 Seating capacity: Are all seats assigned? Yes No N/A Fair or Celebration N/A there any mechanical amusement devices or rides? If yes, describe: Yes No any of the following present: a. Dunk tanks b. Trampolines c. Water slides or other water-type rides d. Paint ball, slat ball If yes to any, and owned or operated by you, attach list and description of each. If owned or operated by others, do they have their own insurance?Attach Certificate(s) of Insurance. Are devices stationary? Will ride operators hold you harmless? Are rides inspected? If yes, by whom: rides have signs clearly marking age, height, and size limitation? Do vendors provide Certificates of Insurance?

9 S62-CG (9/12) 2012 The Travelers Indemnity Company. All rights reserved. Page 4 of 6 Parade N/A 1. Details and length of parade route: 2. Describe motorized vehicles and/or floats: cross streets barricaded? Are there any animals? If yes, explain: Yes No Rodeo, Horse Show, Cattle Show, Etc. N/A 1. Describe EVENT in full detail: 2. Number of EVENT days: Number of events : EVENT is: For Profit Non-profit livestock contractors have their own insurance? Do they provide Certificates of Insurance? Yes No 5. Describe spectator protection and separation from chutes, pens, loading zones: 6.

10 Distance between barriers and spectators: Provide a N/A 1. Estimated attendance for the concert(s) only: 2. Seating is: Assigned Unassigned Capacity of facility used for concert: 3. Type of music being performed: Country Pop (Top 40) Rap Hard Rock Punk Classical Easy Listening Other: 4. List all performers or groups: 5. Are there any SPECIAL effects? Yes No If yes, describe: Haunted House N/A 1. Describe building and construction: Age: Condition: 2. Ratio of attendants to the public: Number of persons per group: Age of clients: children supervised?