Special Events Application

Working With The Following Agent
- Brent Friesth
- Karen Pickering
- Unknown
General Information
Named Insured
First Last
(as it should appear on the policy)
Email
Doing Business As (DBA)
(additional names under which the business operates)
Legal Entity
- Individual
- Corporaiton
- Joint Venture
- Partnership
- LLC
- Sole Proprietorship
- Other
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone:
Cell:
Fax:
Website
Event Specific Information
1. Will the event have or feature any of the following activites:
Rides, Amusement devices, inflatables or recreational devices?
- Yes
- No
Petting zoos or animals?
- Yes
- No
Fireworks or pyrotechnics?
- Yes
- No
Concessionaires, exhibitors or vendors?
- Yes
- No
Is the Purpose of this event a concert or musical event?
- Yes
- No
**Music or entertainment incidental to the event is ok
2. Are overnight accommodations or camping facilities part of the event?
- Yes
- No
3. Is the event held at multiple locations?
- Yes
- No
3. Is the event held annually?
- Yes
- No
Entertainment
If there is a musical performer, please indicate the type of music to be provided/performed:
Event Details
Name Of Event
Expected total attendance at the event
(average daily attendance X no. of days)
Brief Description Of Event:
Dates Of Coverage:
Start Date End Date

(including set up and tear down)
Event Date(s)
Start Date End Date
Hours of Event:
Start am/pm End am/pm

(including set up and tear down)
Location Of Event
Event Location
Venue Name:
Event Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Alcoholic Beverages
Alcohol will be allowed at the event.
- Yes
- No
No alcohol provided by named insured and/or only attendees allowed to bring their own alcoholic beverages.
- Yes
- No
Alcohol will be sold at the event.
- Yes
- No
(e.g.: individual drinks are offered for sale for cash or with pre-purchased tickets).
If alcohol is sold, who holds the liquor license or permit?
- Insured
- Caterer or Vendor
- Facility
- Sponsor
Alcohol will be furnished without a charge at the event.
- Yes
- No
if yes, is the insured required to obtain a liquor license?
- Yes
- No
Alcohol will be both sold and furnished at the event.
- Yes
- No
(e.g.: providing wine and beer for free, but also having a cash bar)
If yes, who holds the liquor license or permit?
- Insured
- Caterer or Vendor
- Facility
- Sponsor
Liquor Liability Coverage
Complete this section only if selecting this optional coverage.
Is the named insured required to obtain a liquor license or permit?
- Yes
- No
If no: Please provide the name ofthe liquor license/permit holder:
Please provide the liquor license/permit number (if applicatble):
Are alcoholic Beverages (please select one)
- Sold?
- Included as a part of the admissions charge?
- Served or furnished without a charge?
If sold, provide the amount of alcoholic beverage sales $
If sold, provide the amount of food sales $
What types of alcoholic beverages are being sold/served?
- Liquor
- Beer
- Wine
Indicate all that apply
Have you ever been fined or had a liquor license/permit revolked or suspended?
- Yes
- No
Has any insurer cancelled or nonrenewed your coverage during the past 3 years?
- Yes
- No
Are patrons allowed to carry alcoholic beverages onto the premisis during your event? (BYOB)
- Yes
- No
Are alcohol sales and consumption contained within a fixed and/or secured area?
- Yes
- No
Has at least one server at this event had formalized awareness training?
- Yes
- No
If yes, please provide the type of training
- TIPs
- TAMs
- TABC
- other
Are ID's checked at the event?
- Yes
- No
Are alcohol sales stopped at least (1) one hour prior to the end of the event?
- Yes
- No
Do you need to add an additional insured for the liquor liability coverage?
- Yes
- No
If yes, Named of Additional Insured for Liquor Liability:
First Last
Additional Insured's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Additional Insured Requests
Complete this section to request additional Insureds on the policy.
Entity Name
First Last
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Additional Insured form requested:
- Yes
- No

Start Date	End Date

Start Date	End Date

Start am/pm	End am/pm

Special Events Application

General Information

Event Specific Information

Event Details

Location Of Event

Alcoholic Beverages

Liquor Liability Coverage

Additional Insured Requests