Film Emporium Special Event Insurance Application First find out: Is my event eligible? How did you hear about us? Please select: Google Yahoo Lycos AOL Altavista MSN Other search engine Link from other website Friend/Colleague Newspaper/magazine advertisement A.R.T. NY Flyer Already a Customer IMPORTANT: Please provide a US address. No PO Boxes. Insured Name Address Address2 City State Please select: Canada Other Country AP/AE Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming Zip Country Entity Type Please Select... Corporation Individual Joint Venture Partnership Other Limited Liability Partnership Trust Non-Profit Limited Liability Corporation Website Primary Contact Last Name First Name E-mail Phone Fax Other phone Event Description Event Name Brief description of event Is my event eligible? What are the dates of the event? Start Month... Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Day... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year... 2001 2002 2003 2004 2005 2006 2007 2008 End Month... Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Day... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year... 2001 2002 2003 2004 2005 2006 2007 2008 What is the cost/budget of your event? Venue Details (Location where event takes place): Venue Name Venue Address Venue City Venue State Please select: Canada Other Country AP/AE Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming Venue Zip Venue Type Indoor Venue Outdoor Venue Attendance Average Daily Spectators Average Daily Participants Number of Days Total Attendance Participant Details # of Exhibitors (No Sales) # of Concessionaires (Non Food Sales) # of Concessionaires (Food Sales) # of Attractions (Performers) Optional Coverages — in addition to general liability do you require : a. Liquor liability? yes no b. Waiver of subrogation? yes no c. Hired & non-owned auto liability? yes no d. Hired & non-owned auto Physical Damage? yes no e. Third-party property damage coverage? NONE $25K $50K $100K $250K $500K $1M $1.5M $2M f. Rented equipment coverage? yes  <- if yes, enter total replacement value no g. Owned equipment coverage? yes  <- if yes, enter total replacement value no h. Spectators & Participants Medical Coverage? yes  <- if yes, enter number of average daily participants no i. Excess Liability Coverage? NONE $1M $2M $3M $4M $5M j. Event cancellation? yes no k. Non-Appearance? yes no l. Door Registration Receipts Coverage? yes no m. Personal Property Coverage Form? yes no Worker's Compensation Is worker's compensation required? yes no Federal ID or Social Security Number Number of full-time Employees Number of part-time Employees Number of Volunteers Total Payroll Payroll Company (if any) Underwriting Questions Please answer the following questions to determine if the production qualifies for short term production insurance 1. Underwriting Questions a. Does the event include any Stunts, Pyrotechnics, Aircrafts, Animals, Hazardous Activities, Car Races, Precision Driving, Injury to Participants, Mechanical Devices, Owned Equipment, Private Armed Security Guards, Events outside U.S., Film Production, Earthquake, Flood, Rap/Hip-Hop, Rock/Metal, Weather, Rides, Water Activities yes no b. The event will take place in the United States only (and not in New Hampshire or Vermont)? yes no c. Confirm only one event can be covered per policy. yes no d. Any private armed security? yes no e. Is event for and/or include a nationally known/recognized person? yes no f. If YES, please name: 2. Claim History Any prior event with any losses of any kind declared by the insured and/or known by the broker? yes no Need help filling out our insurance forms? Click here to see definitions for our insurance forms. Click here to download a sample document that shows how insurance terms are used in an application — this is a "PDF" document and requires Acrobat Reader, which you can download free from Adobe if you don't have it. Paying by credit card? Click here for a credit card authorization form. Please print, and mail a signed copy to us. All insurance sales are non-cancellable and subject to a 3.5% surcharge.