Event Planner Insurance Form

Name of Applicant

Applicant Address

Phone

Email

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Date Established

Class of Business

Business Name (if applicable)

Description of Operations

Estimated Gross Sales for the Next 12 Months

Operations

Exposure

Estimated payroll expense for the next 12 months, including yourself, your full-time, part-time and temporary employees

Number of employees, including yourself, full-time, part-time, and temporary employees

Questions

Does your business use a written contract or statement of work?

Does your business use rented or non-owned vehicles (e.g. an employee's car) for business purposes?

Yes No

Is your business operated out of your home?

Yes No

Your business does not conduct any of the following activities: Automotive repair or sales Food service/restaurant operations Medical services Retail operations Note: This does not include the activities of your clients in any of these industries.

I Agree

Your business is not controlled or owned by any other firm, corporation, or entity.

I Agree

For the entire period of time that you have owned and controlled the business, you have not sold, purchased or acquired, discontinued, merged into or consolidated with another business.

I Agree

What type of events are primarily planned or promoted by your business? Check all that apply

Does your business provide any of the following services or activities: Equipment rentals, Only host or conduct events for your own business, Staffing or catering services, Transportation services?

Yes No

Does your business promote media, artists or entertainers on behalf of or for any entertainment, publishing, music, internet or media company?

Yes No

During the next 12 months, what are the estimated gross sales you will earn from your largest customer?

Tangible Goods or Products Questions

Do you or your business supply, manufacture, or distribute any tangible goods or products?

Yes No

Does your business perform any design, construction, installation, removal, or physical repair of any property or tangible good?

Yes No

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Insurance History

Has your business ever had any commercial insurance cancelled or rescinded? This does not include a prior cancellation for nonpayment of premium.

Yes No

Based upon your knowledge and the knowledge of your business’s current and past partners, officers, directors and employees, during the last five years a third party has never made a claim against your business and you do not know of any reason why someone may make a claim.

I Agree I Disagree

Do you currently have an insurance policy in effect for the coverage requested?

Yes No

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Enter the requested effective date and coverage limits.

Coverage Term Annual policy period: Effective Date

General Liability

Each Occurrence / General Aggregate

Certificates/Blanket Additional Insureds

Waiver of Subrogation

Primary and Noncontributory - Other Insurance Condition

Hired Auto And Non-Owned Auto Liability (Occurrence/Aggregate) - Sublimit

Terrorism

Errors & Omissions

Each Occurrence / General Aggregate

Retention

Coverage Basis

Waiver of Subrogation

Inland Marine

Electronic Data Processing Hardware & Software (owned, leased and rented) Electronic Data Processing Hardware & Software includes coverage for Furniture, Fixtures, Office Equipment and Supplies as well as Tenant Improvements & Betterments. The aforementioned items are blanketed together as a single limit.

Electronic Data Processing Hardware & Software - Maximum per Item

Business Income/Extra Expense

Property in Transit and temporarily within other premises

Detrimental Code (Aggregate/Occurrence)

Terrorism

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Workers' Compensation

Workers Compensation Limits

Waiver of Subrogation

Class Code

If Other?

# Full Time Employees

# Part Time Employees

Payroll-Total W-2, 1099, deferred and other

Payroll Company (if any)

Officers and Owners

Workers Compensation requires that officers and owners be scheduled. Coverage availability for officers and owners will vary depending upon the program and primary state. If there are multiple officers and owners, all must either be excluded or all must be included. Where officers are included, a minimum and/or maximum payroll may be required.

Name

Title

Officer Requirements

Social Security

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When to schedule an Additional Insured

General Liability - Blanket additional insureds are automatically included per the blanket additional insured form attached to the policy. If a third party requires to be specifically listed on the policy via any other form (i.e. CG2026, CG2011, etc), they must be scheduled and an additional premium may apply. Professional Liability - Blanket additional insureds are automatically included per the blanket Professional Liability form attached to the policy. If a third party requires to be specifically listed on the policy, they must be scheduled (no charge). Inland Marine - Blanket loss payee is included. No need to schedule onto the policy unless required by a third party.

Additional Insured Type

Name

Address

Contact Name

Phone

Fax

Email

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