Onsite Consumption

Business Name(Required)

Applicant's Name(Required)

Address(Required)

Street Address City State ZIP Code

Website Address

Email(Required)

Phone No(Required)

Proposed Effective Date (include any set up and tear down dates):

Date From

Date To

12:01 A.M., Standard Time at the address of the Applicant

ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)

Applicant is

Other description

Limits Of Liability and Deductible Requested:

General Aggregate (other than Products/Completed Operations)

Products and Completed Operations Aggregate

Personal and Advertising Injury (any one person or organization)

Each Occurrence

Damage To Premises Rented To You (any one premise)

Medical Expense (any one person)

Other Coverages, Restrictions, and/or Endorsements

Deductible

Name of event

Location address of event and venue name (if applicable):

Description of event (attach any flyers, brochures and/or event website address)

Maximum daily attendance

Total attendance

Sales

Length of event

Estimated age group of audience

From

To

Daily hours of event

No. of Participants

Do participants sign waiver of liability agreements?

Applicant’s experience in conducting events of this or similar nature

Is applicant an event planner/coordinator?

If applicant is the sponsor, does the operator have General Liability insurance?

Is any Marijuana/Cannabis sold or distributed?

Entertainment

Is live entertainment provided?

Is event a rave, rave dance or rave party?

Is there a concert?

Hold-harmless Agreements

Is applicant held harmless by others?

Does applicant agree to hold any third-party harmless?

Is applicant naming anyone as an additional insured?

Stadiums:

Are bleachers or platforms to be used?

Type:

Back and side railings provided?

Construction:

Height in feet:

Age of bleachers or platform:

Are patrons protected from, and warned against, potential flying objects?

Are patrons allowed on the field, track or pit area?

Is public address system clearly audible in all parts of the facility?

Is there a backup electrical supply for lighting and the public address system?

Are premises entrances/exits well lit?

Traffic Control:

Who is responsible for crowd and traffic control?

Are parking areas smooth with clearly marked parking areas and exit roads?

Additional Insured Information:

Additional Insured

Name

Address

Interest

During the past three years, has any company ever cancelled, declined or refused similar insurance to the applicant? (Not applicable in Missouri)

Does risk engage in the generation of power, other than emergency back-up power, for their own use or sale to power companies?

Does applicant have other business ventures for which coverage is not requested?

Prior Carrier Information

List

Year

Carrier

Coverage

Policy No.

Total Premium

Loss History:

Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give rise to claims for the prior five years.

No Losses

Check if no losses last five years

List

Date of Loss

Description of Loss

Amount Paid

Amount Reserved

Claim Status (Open or Closed)

Entertainment

Hold-harmless Agreements

Stadiums:

Traffic Control:

Additional Insured Information:

Prior Carrier Information

Loss History:

Parade:

Political Rally:

Pumpkin Patch (temporary retail lot):

Rodeo:

Under 21 Dance, Graduation Night or Prom: