Annual Theatrical/Musical Production Liability Application

Liability Coverage to Include Participant Third-Party Liability Claims

Contact Name

Contact Person Is

Phone

Fax

Insured Entity Name

Insured is

Address

Event Location

Name of Event

Facility Name

Address

City

State

Zip

Description of Event

Desired Effective Date

Desired Expiration Date

Number of Unique Staff/Volunteers Per Calendar Year (how many different heads over the course of one year? This includes Actors, Directors, Ushers, Stagehands, etc)

Please fill out the following in regards to any other upcoming planned productions in the next year.

Event Date(s)

Event Description

Venue or Facility

Event Date(s)

Event Description

Venue or Facility

Event Date(s)

Event Description

Venue or Facility

Does your organization currently utilize a waiver of liability form? (if you do not know the answer, select No)

Yes No

Accident medical coverage is required in order to place participant liability coverage

Volunteer Accident coverages available:
Eligibility: All Participants & Staff of the Policyholder.
Benefits
Up to $25,000.00 Maximum Medical Benefit per Claim
Up to $5,000.00 Accidental Death/Dismemberment
Dental Benefit: Included in Maximum Medical Benefit
Excess coverage will be offered on quote with a deductible.

Will your organization be serving or selling alcohol?

Yes No

If yes, please describe

Has this event been held in the past by this applicant?

Yes No

If so, were there any losses or claims?

Please Describe

Additional Insured

(Usually the facility hosting the event)

Name

Street Address

City

State

Zip

Phone

Will you require more than one additional insured?

Yes No

Fraud Warning

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties, as well as the withdrawal of such insurance and/or the denial of any coverages and/or claims.

Signed by Applicant

Date

Printed Name of Applicant

Broker Information (if applicable)

Agency Name

Representative

Phone

Event Insurance Now
Phone (877) 305-5040
Fax (503) 977-5848
events@eventinsurancenow.com

Apply Online
Now

Agents & Brokers
Start Here