Film Emporium Trade Show Insurance Application 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 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 Years Experience Primary Contact Last Name First Name E-mail Phone Fax Other phone Event Description Trade Show Name Trade Show Description Exhibitor's Cost/Budget Description of Exhibitor's Activities Venue Details (Location where the Trade Show 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 Trade Show Organizer Details Name of Organizer Address 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 Effective/Expiration Date 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 Exhibitor Details Booth Size (Square Feet) How many people will visit your booth? Type of Exhibitor Exhibitors -No Sales Concessionaires - Food Sales Concessionaires - Non Food Sales Products Liability (Required only for Concessionaire- Non Food Sales) Please select: Clothing Apparel Records Tapes CD's Posters Badges Photos Stickers Other Inland Marine Rented Equipment (Equipment of Others) Excluded 5,000 10,000 15,000 20,000 25,000 35,000 50,000 75,000 100,000 150,000 200,000 250,000 300,000 350,000 400,000 450,000 500,000 550,000 600,000 650,000 700,000 750,000 800,000 900,000 1,000,000 1,250,000 1,500,000 1,750,000 2,000,000 Third Party Property Damage Excluded 25,000 50,000 100,000 250,000 500,000 1,000,000 1,500,000 2,000,000 Owned Equipment: Scheduled (Replacement Cost) Excluded 5,000 10,000 15,000 20,000 25,000 35,000 50,000 Owned Equipment: Unscheduled (Actual Cash Value) Excluded 5,000 10,000 15,000 20,000 25,000 35,000 50,000 General Liability General Liability (Occurrence/Aggregate) Excluded 1,000,000 2,000,000 Certificates/Blanket Additional Insureds Excluded Included Waiver of Subrogation Excluded Included Liquor Liability (Occurrence/Aggregate) Excluded 1,000,000 Automobile Hired/Non-Owned Liability Excluded 1,000,000 Hired and Non-owned Auto Physical Damage (Occ/Agg) Excluded 125,000,000/2,000,000 Excess Liability Per Occurrence / Aggregate Excluded 1,000,000 2,000,000 3,000,000 4,000,000 5,000,000 Workers' Compensation Limits Excluded 1,000,000 # of Full Time Employees (Over 20 hrs./wk.) # of Full Time Employees (Under 20 hrs./wk.) Total Payroll Underwriting Questions Please answer the following questions to determine if the trade show exhibitor qualifies for this program. 1. Underwriting Questions a. Does the event Exhibitor's Booth include any of the following? Stunts, Pyrotechnics, Hazardous Activities, Mechanical Devices, Animals, Rides, Rap/Hip-hop/rock/metal music performances, massage machines yes no b. Exhibitor will be stationed behind their booth or in a designated area throughout the trade show? yes no c. Confirm only one trade show will be covered per policy. yes no d. The trade show will take place in the United States? yes no e. Is the insured responsible for any type of security or maintenance personnel? yes no 2. Claim History Any losses relating to trade show exhibits? 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.