Philadelphia Insurance Companies

Special Event - Supplemental Application

PIIC Producer:
Broker:

PIIC Producer:

Broker:

Submission Requirements:

Currently valued, carrier-generated Loss Runs for the current year and the last three years (for accounts where premium exceeds $5,000).
Copy of rental agreement or contract to rent or use venue.

Account Information

Applicant Name:
Address:
Web Site:		E-Mail Address:
Contact Person (Billing):		Phone:
Contact Person (Loss Control):		Phone:
Effective Dates Requested:
Event Gross Revenues:
For Profit:	Individual Partnership Corporation Association Other:
Non-Profit:
Years this entity in business:		Years experience of this owner:
Has the applicant had any claims filed against it in the last four years?	Yes No
If yes, please provide details:

Applicant Name:

Address:

Web Site:

E-Mail Address:

Contact Person (Billing):

Phone:

Contact Person (Loss Control):

Phone:

Effective Dates Requested:

Event Gross Revenues:

For Profit:

Individual Partnership Corporation Association Other:

Non-Profit:

Years this entity in business:

Years experience of this owner:

Has the applicant had any claims filed against it in the last four years?

Yes No

If yes, please provide details:

Description of Event:

Dates:

Times:

(Attach brochure or promotional materials if applicable.)

Total Number of Attendees

Number of Attendees per day:

Total Number of Volunteers

Number of Volunteers per day:

Revenue Generated:

Admission Fees
Liquor Sales
Food Sales
Merchandise

Is alcohol being served?

Yes No

By whom?

Has the server provided evidence of liquor liability insurance?	Yes No
Is Liquor Liability coverage desired? If yes, complete liquor liability supplement.	Yes No

Name of Venue:

Seating Capacity

Seating Type

(Permanent Grandstands, Temporary Bleachers)

Number of Exhibitors

Who is supplying security at venue?

(If private firm, they must have insurance and name you as an additional insured.)

Describe the safeguards in place to prevent injury to spectators:

Describe first aid/medical arrangements:

Is the event limited to venue grounds?

Yes No

If no, provide details:

Describe first aid/medical arrangements:

Swimming:

Yes No

If Yes, are certified lifeguards on duty?

Yes No

Are they CPR trained?

Yes No

Are certificates received by Insured?

Yes No

Athletic Events

Yes No

If Yes, is athletic participant coverage desired?

Yes No

Performers

Yes No

If yes, please list all performers:

Are you required to provide certificates of insurance to any other entity?

Yes No

If yes, please provide names of certificate holders and their interest:

10.

Other Comments:

Applicant.s Statement and Declarations

The applicant declares to the best of his / her knowledge the information contained in this application and all supplements attached to be true and that no material facts have been suppressed or misstated. The applicant further understands that any false or fraudulent statements or misrepresentations could result in termination or voidance of any insurance contract issued from the information stated herein.