Will there be metal detectors at all entrances AND exits for all Attendees?

Yes No

Will there be at least 1 security personnel for every 50 attendees?

Yes No

Please choose option!

APPLICANT / COMPANY NAME

Company Entity

Is the Applicant either a US based entity or Individual who is a US resident, citizen, or has an ACTIVE student or work VISA? (Visa must be active throughout the insurance policy period)

Yes No

CONTACT INFORMATION

First Name

Last Name

Email Address

Confirm Email

Phone

Fax

Mailing Address

Zip Code

City

State

What is the total number of years of Experience of the applicant?

EVENT INFORMATION

Event Name

Event Website

Event Description

Will this event take place outside of the United States?

Yes No
Please provide the location address

Start Date

End Date

Please explain why the total number of event days are more than 5 days

LOCATION OF EVENT

Venue Name

Venue Address

Venue Zip Code

Venue City

Venue State

DOES THE FACILITY CARRY LIABILITY INSURANCE?

Yes No

What is the estimated spectators per day?

What is the actual number of event days?

What is the estimated gross receipts?

What is the gross revenue?

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ADDITIONAL INSUREDS

Name

Addresss

Zip Code

State

City

Name

Addresss

Zip Code

State

City

WILL THE EVENT BE INDOORS OR OUTDOORS?

INDOORS OUTDOORS
Will the area be fenced or enclosed?

Yes No
ARE YOU RESPONSIBLE FOR PARKING?

Yes No
What is the square footage of parking area?
WILL THERE BE ANY DEMONSTRATIONS OR EXHIBITIONS?

Yes No
Please describe

ARE SEATS OF TEMPORARY OR PERMANENT CONSTRUCTION?

TEMPORARY PERMANENT
DESCRIBE TYPE OF SEATING PROVIDED
FOR OUTDOOR EVENTS, DOES THE EVENT END NINETY MINUTES PRIOR TO SUNDOWN?

Yes No
Is there permanent lighting over all spectator areas and parking lots?

Yes No

IF A STAGE IS INVOLVED, IS THE STAGE OF TEMPORARY OR PERMANENT CONSTRUCTION?

TEMPORARY STAGE PERMANENT STAGE
Who is responsible for setting up the stage?
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 TEMPORARY LIGHTING INVOLVED?

Yes No

Who is responsible for hook up the lighting?

IF OTHER THAN APPLICANT, is a certificate of insurance provided?

Yes No

IF OTHER THAN APPLICANT, is Applicant Named as Additional Insured?

Yes No

IS A TENT INVOLVED?

Yes No

Who is responsible for the set up of the tent?

IF OTHER THAN APPLICANT, is a certificate of insurance provided?

Yes No

IF OTHER THAN APPLICANT, is Applicant Named as Additional Insured?

Yes No

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ADDITIONAL INSUREDS

WILL USHERS BE USED FOR SEATING PURPOSES?

Yes No

Who is providing the ushers?

Is a certificate of insurance provided?

Yes No

Is Applicant Named as Additional Insured?

Yes No

Is Seating Assigned For Usher?

Yes No

What is the Number Of Vendors Or Trade Booths?

Are vendors or trade booths required to provide proof of insurance?

Yes No

Who is responsible for providing food or drinks?
IF OTHER THAN APPLICANT, is a certificate of insurance provided?

Yes No
IF OTHER THAN APPLICANT, is Applicant Named as Additional Insured?

Yes No

WILL YOUR COMPANY BE SELLING LIQUOR AT THIS EVENT?

Yes No

Does the Applicant have a valid liquor license?

Yes No
What is the estimated liquor sales of this event? (total)

Will you be hiring a vendor to sell liquor as this event?

Yes No
Will the vendor have liquor liability and name your company as an additional insured?

Yes No

What is the average age of attendees?
What measures are in place to prevent the service of alcohol to minor and/or intoxicated persons?

IS THE APPLICANT PROVIDING OVERNIGHT ACCOMMODATIONS? (i.e. camping)

Yes No

Please Describe

Who is responsible for providing security?

IF OTHER THAN APPLICANT, is a certificate of insurance provided?

Yes No

IF OTHER THAN APPLICANT, is Applicant Named as Additional Insured?

Yes No

IS THE SECURITY PROVIDED ARMED OR UNARMED?

ARMED UNARMED

IF THE EVENT IS BEING HELD ON A STREET OR OTHER PUBLIC PLACE OF VEHICULAR ACCESS, WHAT PROTECTION IS BEING USED BETWEEN THE STREET AND THE SIDEWALK?

ARE FIREWORKS OR PYROTECHNICS TO BE USED?

Yes No
IF YES, Please Describe
HAS THIS EVENT BEEN HELD IN THE PAST BY THE APPLICANT?

Yes No
IF YES, For how many years?
HAS YOUR PRIOR INSURANCE EVER BEEN CANCELLED?

Yes No
HAS YOUR PRIOR INSURANCE EVER REFUSED TO RENEW?

Yes No
HAVE YOU HAD ANY PRIOR EQUIPMENT, ENTERTAINMENT, PRODUCTION OR BUSINESS INSURANCE?

Yes No
Please Describe Any Losses Over $5,000 For The Past 5 Years
Will you (the applicant) be hiring any subcontractors for the events you’re looking to insure?

Yes No
DO THESE SUBCONTRACTORS CARRY THEIR OWN INSURANCE NAMING YOU AS ADDITIONAL INSURED?

Yes No
WILL THERE BE TEMPORARY STRUCTURES INSTALLED/BUILT FOR YOUR EVENT?

Yes No
Please Describe

Who is responsible for installing the temporary structure?

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Worker Compansation for

What is the total payroll paid to employees (and 1099s) from

How many are full-time?

How many are Part-time?

Total Payroll

NUMBER OF PERFORMERS (OTHER THAN DANCE)

NUMBER OF PERFORMERS (DANCE)

NUMBER OF CREW

GENERAL LIABILITY

SELECT YES OR NO
Yes No

COVERAGE
EVENT LIABILITY

LIMITS
$1,000,000 / $1,000,000 $1,000,000 / $2,000,000 $1,000,000 / $3,000,000 $1,000,000 / $4,000,000 $1,000,000 / $5,000,000

Yes No

CITY / SPECIAL CERTIFICATES (I.E. FILM PERMIT OFFICE)

Yes No

WAIVER OF SUBROGATION

Yes No

PRIMARY AND NON-CONTRIBUTORY

AUTO LIABILITY

PLEASE NOTE: NON-OWNED & HIRED AUTO PHYSICAL DAMAGE IS EXCLUDED

SELECT YES OR NO

COVERAGE

Yes No

NON-OWNED & HIRED AUTO LIABILITY

Will all drivers (including any crew using their own vehicles) be at least 25 years of age?

Yes No
Do all drivers have a valid united states driver’s license ?

Yes No
Will you use any vehicles that seat more than 12 people?

Yes No
Will you use a bus or van primarily to transport any people?

Yes No
Please describe how any vehicles will be used (including rented vehicles or crew using their own vehicles)
What is the total cost you are paying to rent all your vehicles?

EVENT & PRODUCTION EQUIPMENT

PLEASE NOTE: DOES NOT COVER ANY AUTO PHYSICAL DAMAGE

SELECT YES OR NO

COVERAGE

LIMITS

Yes No

RENTED PROPS, SETS, & WARDROBES

Yes No

RENTED PRODUCTION AND EVENT RELATED EQUIPMENT

WHAT DAY ARE YOU PICKING UP YOUR EQUIPMENT?
WHAT DAY ARE YOU RETURNING YOUR EQUIPMENT
Currently the policy excludes theft from unlocked vehicles. Would you like to ADD coverage for theft from an unlocked vehicle?

Yes No
Do you have any pre-existing damages on any of the equipment or items you are looking to cover on this policy?

Yes No
IF Yes, Please describe in detail.

If you had to fix the damages today, how much would it cost to fix everything (feel free to estimate)?
Please answer the following question based on how you plan to store your equipment during this policy term. This information is needed for underwriting purposes. Our policy covers theft from an unattended vehicle, regardless of how you answer the next question.

I Understand

Will you ever leave any of your equipment in a vehicle UNATTENDED?

Yes No
What is the maximum value of equipment left in your vehicle unattended?

How much of the $XXX may be left Unattended OVERNIGHT (maximum amount)?

How often does this happen?

Of the $XXXX of equipment that is left unattended, what is this gear comprised of (i.e. cameras, lenses, grip equipment, etc.)?

What kind of vehicle will you leave your equipment in (please describe in detail)

What security measures will be taken to protect the equipment while left in a vehicle?

Does the equipment being insured have a GPS tracking device?

Yes No

Does the tracking device signal send to a monitored, remote device or security system?

Yes No

Does the vehicle have an alarm system?

Yes No

Does the alarm signal go to a monitored, remote device or security system?

Yes No

Please explain

Please select all that apply to how you may leave your equipment in an unattended vehicle:

I LEAVE MY EQUIPMENT IN AN UNATTENDED VEHICLE...

Only if it's an emergency or rare situation when I cannot store it anywhere else

For short periods of time (less than 30 minutes) including for food and bathroom breaks

For hours at a time, but not overnight

For days at a time, including overnight

All the time, including storing it in my vehicle

Other frequencies

Where will the vehicle be parked when left unattended? (mark all that apply)

City Street

Residential Street

Residential Garage (private home)

Residential Shared Garage (i.e. apartment complex)

Parking Garage:

If you marked “Parking Garage” please also mark all that apply below to the parking garage:

With 24 hour Security Guard and Surveillance

With limited surveillance

Restricted Access (Key Card)

Fenced

Gated

Lighted

Not Guarded

No Lot Attendant

Other:

Other

*NOTE: LIMITS FOR RENTED EQUIPMENT SHOULD BE THE TOTAL REPLACEMENT COST VALUE OF ALL EQUIPMENT AND/OR PROPS RENTED AT ANY ONE TIME.

ACCIDENT MEDICAL COVERAGE

PLEASE NOTE: THIS IS NOT WORKERS COMPENSATION COVERAGE. IT REIMBURSES FOR MEDICAL EXPENSES SUSTAINED TO CAST OR CREW WHILE PARTICIPATING IN THE FILMING OPERATIONS, EXCESS OF ANY EXISTING HEALTH INSURANCE AVAILABLE)

SELECT YES OR NO
Yes No

COVERAGE
ACCIDENT MEDICAL

LIMITS
$10,000 per person per claim $25,000 per person per claim $50,000 per person per claim $100,000 per person per claim

Number Of Cast Members

Number Of Crew Members
Are any above members currently covered by Workers Compensation?

Yes No

WORKERS COMPENSATION

NOTE: IF YOUR EVENT INVOLVES ANY HAZARDOUS ACTIVITIES OR STUNTS, WE CANNOT QUOTE WORKERS COMPENSATION

SELECT YES OR NO

COVERAGE

Yes No

WORKERS COMPENSATION

TOTAL PAYROLL FOR ALL CAST AND CREW MEMBERS EXCLUDING OWNERS

How many are full-time?

How many are Part-time?

Total Payroll

NUMBER OF PERFORMERS (OTHER THAN DANCE)

NUMBER OF PERFORMERS (DANCE)

NUMBER OF CREW

ADDITIONAL STATES (other than the state of the applicant mailing address)

NAME OF OWNERS MUST BE LISTED (The below individual(s) will be excluded from Workers Compensation coverage)

1 FULL NAME

TITLE

2 FULL NAME

TITLE

3 FULL NAME

TITLE

FEDERAL ID NUMBER OF CORPORATION OR SOCIAL SECURITY NUMBER OF OWNER

Yes No

WAIVER OF SUBROGATION

WHAT IS THE NAME OF THE COMPANY REQUESTING THE WAIVER OF SUBROGATION?

OFFICERS & OWNERS (Include/Exclude)

SELECT ANY ONE
INCLUDE EXCLUDE

COVERAGE
OFFICERS & OWNERS

No.

First Name

Last Name

#SSN

Title

How Did you Hear About Us?

Where?

ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PROVIDES FALSE INFORMATION IN AN APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES. I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND COVERAGE IS NOT APPLICABLE UNTIL ACCEPTED BY ATHOS INSURANCE SERVICES.

I understand that this application is just a starting point to apply for insurance and may result in additional questions from Athos Insurance, in order to receive better quote options.

SIGNATURE OF APPLICANT

DATE

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Please provide us with any notes regarding your submission and/or all insurance requirements for this project/event.

Please upload the insurance document for this project/event.

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OR

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Special Event Insurance Application