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SPECIAL EVENT APPLICATION - Surplus Ins

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: 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 complet

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Transcription of 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: 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?

2 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? 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?

3 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? 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?

4 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. 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. Policy limits on the Igniter s policy: 3.

5 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. 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.

6 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? 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?

7 Do they provide Certificates of Insurance? Yes No 5. Describe spectator protection and separation from chutes, pens, loading zones: 6. 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? Are there separate entrances and exits? Has the house been inspected by a Fire Marshall?

8 Does the house meet all local, city and state codes? Yes No 7. Describe any temporary structures: 8. Indicate if any of the following are present: Unlit Stairs Moveable Floors Sinking Floors Slides Fire or Flash Powders Suspended Bridges Electric Shock Devices Describe SPECIAL effects: S62-CG (9/12) 2012 The Travelers indemnity Company. All rights reserved. Page 5 of 6 you use empty hangmen ropes, knives, swords or similar items? If yes, explain: Yes No stairwells lit and in good condition? Do you have lead and follow-up guides? Do you have a door monitor? Does the public participate in stunts? If yes, explain: 14. Does anyone touch the public? Racing/Motorized Vehicle EVENT N/A 1. Type of race/ EVENT ( Mud Rallies, Tractors, Trucks, etc.): 2. Track Name: 3. Planned for current year: Number of EVENT Dates: Held last year: 4.

9 Attendance per EVENT Date: Average: Maximum: 5. Track Description - Attach diagram showing the following: x Location of all grandstands/bleachers and any other area where spectators are allowed. x Shape of track (straight, oval, serpentine, etc.) x Barriers ADDITIONAL INSUREDS any Additional insured s required? If yes, list name and describe interest of each: Yes No you required to sign a lease agreement? Are you held harmless by others? Do you agree to hold any third party harmless? If yes, indicate who: For information about how Northland compensates its agents, brokers and program managers, please visit this website: you prefer, you can call the following toll-free number: 1-866-904-8348. Or you can write to us at Northland Insurance Companies, c/o Law Department, 385 Washington St., St. Paul, MN 55102. This APPLICATION , including any material submitted in conjunction with the APPLICATION or any renewal, does not amend the provisions or coverages of any insurance policy or bond issued by Northland.

10 It is not a representation that coverage does or does not exist for any particular claim or loss under any such policy or bond. Coverage depends on the facts and circumstances involved in the claim or loss, all applicable policy or bond provisions, and any applicable law. Availability ofcoverage referenced in this document can depend on underwriting qualifications and state regulations. S62-CG (9/12) 2012 The Travelers indemnity Company. All rights reserved. Page 6 of 6 FRAUD STATEMENTSARKANSAS, DISTRICT OF COLUMBIA, MARYLAND, NEW MEXICO, AND RHODE ISLAND:Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfullyin MD) presents false information in an APPLICATION for insurance is guilty of a crime and may be subject to fines and confinement in :It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company.


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