General Cancellation Application

Client Information
Organization Information
*Company/Organization:

Entity Type:
*Address:(No PO Boxes):

Suite, Floor, ect..:
*City:

*State - Zipcode:
 

Contact Information
*First Name:

*Last Name:

*Phone:

*Email:

*What is the usual business of the Applicant(s)

*How long engaged therein?


Event Information
*Name of Event:

*Type of Event:

*Has this/have these performance(s) or event(s) been held before? Yes No
*What is/are the involvement(s) of the Applicant(s) in performance(s) or event(s)
*What is/are the experience(s) of the Applicant(s) in this capacity?
*Is/are the performances(s) or event(s) part of a larger production, promotion, series or tour? Yes No
Event Dates
*Event Date 1:
from to
*Event Date 2:
from to
*Event Date 3:
from to
*Event Date 4:
from to
*Event Date 5:
from to

If the event is longer than five days please attach additional dates and times on a separate sheet and email to
Sales Team

What allowance in the itinerary has been made for:
*Travel delay?
*Set up time?
*'Stand-by' dates?
Venue Information
*Venue Name:

*Address:

Address Additional:
*City:

*State, *Zipcode
 
*Location Information:
Please attach a copy of the contract with the venue and email it to Sales Team.
*Will the event venue require construction work? Yes No
*Will adverse weather conditions preclude the fulfillment of the event? Yes No
Only for non- appearance coverage
Would the non-appearance of any individual, group, act, team, etc. preclude the fulfillment of the event? Yes No
Details of (all) person(s) to be insured.(only for non- appearance coverage)
Name(s), age(s) and participation, (only for non- appearance coverage)
Has any person to be insured any history of non-appearance? Yes No (only for non- appearance coverage)
Has any provision been made for Understudies or Substitutes? Yes No (only for non- appearance coverage)
Is/are the person(s) to be insured suffering from any physical, psychological or other medical conditions? Yes No
Is/are the person(s) to be insured undergoing any form of medical or other treatment? Yes No
Is/are the person(s) to be insured following any prescribed medical regime? Yes No (only for non-appearance coverage)
*Have all necessary arrangements for the successful fulfillment of the performance(s) or event(s) to be insured been made?
Yes No
*Have all necessary licenses, visas, and/or permits been obtained and have all contractual arrangements been confirmed in writing? Yes No
Please complete both of the following categories (see definitions listed below) and please indicate which amount is to be insured:
*Gross Revenue from Event (A) $
*Expenses from Event (B) $
*Sum Insured = (either A or B above)

Please explain justification of the Sum Insured, explaining how the dollar amount provided was calculated. If possible, please attach the budget for the Event and send it to Sales Team.

DEFINITIONS OF CATEGORIES
GROSS REVENUE: All monies paid or payable to the Applicant from every source arising out of the Event
EXPENSES: The total of all costs and charges incurred by the Applicant for, and in connection with, the planning, preparation, and staging of the Event.
*Do these sums represent the full extent of your financial responsibilities? Yes No
*If the performance(s) or event(s) has/have been held before under the present management or any other, has there ever been a loss? Yes No
*Has the Applicant sustained any loss or damage during the last five years which would have been covered by this type of insurance had it been in force? Yes No
*Has the Applicant had similar insurance, (as applied for herein), declined, canceled or renewal refused? Yes No
*Are there any other material facts or items of information with regard to the proposed performance(s) or event(s) which should be disclosed? Yes No (A material fact is one likely to influence acceptance or assessment of this proposal by Underwriters)


FRAUD STATEMENTS Signing this application does not bind the Applicant or the Company to complete the insurance, but it is understood and agreed that the information contained herein shall be the basis of the contract should a policy be issued. If any of the above questions have been answered fraudulently or in such a way as to conceal or misrepresent any material fact or circumstance concerning this insurance or the subject thereof, the entire policy shall be void.
* To the best of my knowledge and belief the information provided in this application, whether in my own hand or not, is true and I have not withheld any material facts.
* I understand that non-disclosures or misrepresentation of a material fact will entitle the company to void the Insurance.
* I understand that signing this Application does not bind me to complete the insurance but agree that should an insurance policy be issued, this Application and the statements made therein shall form the basis of the insurance policy.


Applicant
How did you hear about us?
Preferred contact method
Email - Phone - Fax
*Applicant Signature:

*Applicant Title: