Application for Public Liability

Name of Applicant

Street Address

Phone

Name of Event

Dates of Event

Time(s)

Location of Event

Name of Facility

Street Address of Facility (if other than event location)

Description of Event

Is this Event Located Indoors or Outdoors?

Indoors Outdoors

If Outdoors, Is the Area Fenced or Enclosed?

Yes No

What is the Estimated Attendance Per Day?

What is the Price of Admission?

Additional Insureds

(typically the venue or facility requiring this coverage)

Name

Address

City

State

Zip

Phone

Relationship

Will you require more than one additional insured?

Yes No

If the Event is Outdoors, Does the Event End Ninety Minutes Prior to Sundown?

Yes No

If No, Is there Permanent Lighting over all Spectator Areas and Parking Lots?

Yes No

Who is Providing the Food and/or Drink?

If Other than the Applicant, is a Certificate of Insurance Provided?

Yes No

If Other than the Applicant, is Applicant Named as Additional Insured?

Yes No

Is Liquor being served (given away) at this event, not sold in any way?

Yes No

Is Liquor to be Sold at this Event?

Yes No

If sold, does the entity selling the alcohol have a state issued permit/license?

Yes No

If Yes, is there a Liquor Liability Policy In-Force?

Yes No

Is the Applicant Named as an Additional Insured?

Yes No

Is the Applicant Providing any Overnight Accommodations such as Camping?

Yes No

If Yes, Please Describe

Who is Responsible for Providing Security?

Is the Security Provided Armed or Unarmed?

Has this Event been held in the past by the Applicant?

Yes No

If Yes, For how many Years?

Please Describe any Losses or claims in the last 3 years.

Has your Prior Insurance Ever Been Cancelled?

Yes No

Has your Prior Insurance Ever Refused to Renew?

Yes No

Standard Limits of Liability will be offered.

$ 3,000,000 General Aggregate
$ 1,000,000 Products Aggregate
$ 1,000,000 Each Occurrence
$ 1,000,000 Personal/Adv Injury
$ 100,000 Fire Damage
$ usually excluded Medical Payments

If higher limits of liability or additional coverages are required, please indicate here

Signature of Applicant

Date

Broker Information (if applicable)

Agency Name

Representative

Phone

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

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