denotes a required field.

Association/Organization Information
Association or Organization holding the Event(s)
Required

Date Association/Organization Formed
Required

Contact Person
Required

Dates

Policy effective dates requested: (maximum 12 months)

From
Required

To
Required

*Must be at least 14 days prior to the first start date for all scheduled Events.
Address
Mailing Street Address
Required

City
Required

State
Required

Zip
Required

Email
Required

Phone
Required

Fax
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Website
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Primary Event
Title and Description of Event
Required

Venue Name
Required

City
Required

State
Required

Zip
Required

Date the Event is Open From
Required

Date Open To
Required

Total number of registered attendees
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Number per day
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Total number of volunteers
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Number per day
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1)
Is there a Principle Speaker, Keynote Speaker, or Act which is the principle purpose of any Event?
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Please Note: Coverage is NOT available.
2)
Please provide the projected revenue by category for your Primary Event

A) Registered Attendees’ Fees

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B) Exhibitors’ Fees

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C) Sponsorship Fees

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D) Public Gate Receipts

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E) Other Sales

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TOTAL EXPENSES (for the Event)

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GROSS REVENUE

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NET PROFIT (GROSS REVENUE less EXPENSES)

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3)
Do the sums identified in response to Question 2 (above) represent the full extent of your financial responsibilities?
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  If No, please provide details
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4)
Has this Event been held before?
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If Yes, please explain how often
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5)
Is pre‐registration required for attendees?
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If No, please provide details
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6)
Is the Event open to the public?
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If Yes, how many public attendees are expected?
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7)
Will the Event be held outdoors?
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Will the Event be held under canvas?
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In the event of adverse weather conditions, what is your backup plan?
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8)
Will the Venue require or undergo construction work, prior to or during the Event(s)?
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If Yes, please provide details
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9)
Does your Event include a Golf Tournament?
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If Yes, Date
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Number of Participants
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Do you desire Hole‐in‐One coverage?
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Limit or Value Desired
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10)
Do you desire Hotel Block Penalty coverage?
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Limit or Value Desired
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11)
Does the Event include any teleconferencing, satellite or video transmission by internet that you desire coverage?
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If Yes, please provide details
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12)
Will adverse weather conditions preclude the fulfillment of the Event?
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If Yes, please provide details
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13)
Would the non‐appearance of any individual, group, act, team, etc. preclude the fulfillment of the Event?
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If Yes, please provide details
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14)
Do you have a Ticket or Registration Refund Policy?
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If Yes, please provide details
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15)
Have all necessary arrangements for the successful fulfillment of the Event been made?
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If No, when will these arrangements be fulfilled? (Date)
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16)
Have all necessary licenses, visas and/or permits been obtained?
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If No, when will these arrangements be fulfilled? (Date)
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17)
Have all contractual arrangements been confirmed in writing?
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If No, please explain and provide dates
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18)
Do all vendors and service providers for each Event carry appropriate insurance coverage?
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If No, please explain
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19)
Do you have a contingency plan if the Event is delayed or postponed?
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If Yes, provide full details
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THE FOLLOWING QUESTIONS ARE ONLY APPLICABLE FOR NON‐APPEARANCE OF PRINCIPLE SPEAKER COVERAGE
20)
Do you desire non‐appearance coverage for your speakers(s)?
Required

Please click and skip the questions on the current page.

Keynote Speaker


Principle Speaker Name
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Age
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Role
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Duties
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Has this person had any incidents of non-appearance?
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If Yes, please explain
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Speaker 2

Speaker Name
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Age
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Role
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Duties
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Has this person had any incidents of non-appearance?
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If Yes, please explain
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Speaker 3

Speaker Name
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Age
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Role
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Duties
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Has this person had any incidents of non-appearance?
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If Yes, please explain
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Speaker 4

Speaker Name
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Age
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Role
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Duties
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Has this person had any incidents of non-appearance?
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If Yes, please explain
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21)
Does the Applicant have a written contract for the appearance?
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22)
Is/are the person(s) to be insured suffering from any physical, psychological conditions?
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If Yes, provide full details
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23)
Is/are the person(s) to be insured undergoing any form of medical or other treatment?
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If Yes, provide full details
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24)
Is/are the person(s) to be insured following any prescribed medical regime?
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If Yes, provide full details
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25)
Do you have any further material facts to disclose?
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If Yes, provide full details ((Material facts which might influence the acceptance or assessment of the application))
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26)
Have there been, at any time within the last five (5) years, a loss or circumstances which would have been covered by this insurance?
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If Yes, provide full details
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27)
Does any person proposed for this coverage have knowledge or information of any facts, circumstances or situations, actual or threatened, which might possibly give rise to a claim under the proposed coverage?
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If Yes, provide full details
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Any additional comments regarding this application
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Please attach copies of following documents.
Detailed budget of Expenses and Gross Revenues for this event
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Registration Forms for participants
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IT IS AGREED THAT IF THERE IS KNOWLEDGE OR INFORMATION OF SUCH FACTS, CIRCUMSTANCES, OR SITUATIONS AFTER THE COMPLETION DATE OF THIS APPLICATION, AND BEFORE THE DATE INSURANCE COMMENCES FOR THE EVENT, YOU MUST DISCLOSE THE CIRCUMSTANCES TO THE COMPANY IMMEDIATELY, AS THIS MAY AFFECT INSURANCE.

Person designated to receive all notices from the Company or its authorized representative concerning the coverage:
Name
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Title
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Company
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Company Address
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City
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State
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Zip
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Please read the Fraud Statement pertaining to the state in which the Association or Organization is located.



FRAUD STATEMENT

STANDARD NOTICE TO ALL APPLICANTS (other than applicants in states listed below): Any person who knowingly presents false information in an application for insurance or knowingly presents a false or fraudulent claim for payment of a loss or benefit is guilty of insurance fraud, which is a crime, and may be subject to fines and confinement in prison.

State laws require us to include the following fraud notices:

Notice to the Applicant(s): 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 may subject person to criminal and civil penalties.
Colorado 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. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant with regard to a settlement or award payable frominsurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
District of
Columbia
Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/ or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
Florida Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or any application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Kentucky Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing 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.
Maine It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
Minnesota A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
New Jersey Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
New York Any person who knowingly and with intents 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 crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Ohio Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma Warning: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Oregon Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) By submitting and application or (2) by filing a claim containing false statement as to any material fact may be violating state law.
Pennsylvania 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.
Tennessee It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include Imprisonment, fines and denial of insurance benefits.
Texas If a life, health and accident insurer provides a claim form for a person to use to make a claim, that forms just contain the following statement or a substantially similar statement “any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Virginia Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.
West Virginia Any person who knowingly presents a false or fraudulent claim for payment or a loose or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

I have read the Fraud Statement pertaining to the state in which the Association or Organization holding the Event(s) is located.
Required

Was an agent was involved in the completion of this questionnaire, please provide the following information:
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Producer
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Producer/Agency Surplus Lines #
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Agency
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Agency Address
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ALL QUOTATIONS ARE SUBJECT TO THE RECEIPT AND ACCEPTABLE REVIEW OF THE APPLICATION AND OTHER UNDERWRITING INFORMATION BY THE UNDERWRITER.

Name of person authorized to sign this Application
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Title (President, Chairperson or Executive Director)
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Applicant Email
Required (Used only for purposes of this application)

Digital Signature
Required

(By typing your name in this box and clicking submit you are accepting the terms of this application.)

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