Organization Name
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Mailing Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
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(###)
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####
Email
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Event Organizer Contact First and Last Name
State the experience of the Organizer of this Event with events of the type and size proposed.
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State the interest of the Proposer (i.e. the person to be indemnified) in the Event(s) to be insured (e.g. Organizer)
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Has the Proposer event been declared bankrupt?
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Has the Proposer ever been disqualified from being a Company director?
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Has the Proposer ever been involved as an owner, director or partner with any Company that went into receivership, administration or liquidation?
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Has the Proposer ever been convicted (or charged but not tried) of any criminal offense involving dishonesty of any kind?
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Has the Proposer ever suffered a loss whether insured or otherwise in respect of his/her involvement in any type of Event?
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If YES, please provide full details including Date(s), Cause(s) (NB "Bad Weather" is sufficient) and Loss Amount($)
Name Of Event
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Full description of event and all activities:
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Venue of Event (Name and location address)
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Is/Are the Venue(s)
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If the event venue is (a) in a temporary structure, (b) under canvas, (c) outdoor uncovered, or (d) a combination of any, please provide full details of the Venue site including a descriptive brochure if available
Is the Venue undergoing or due to undergo any construction or refurbishment work?
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If you have answered YES to the above question, please provide full details.
Is Car Parking other than on tarmac provided for the Event?
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If you have answered YES to the above Question, please state full details including who is providing the land for the car parking.
Please state Period at Venue(s), including start date and finish dates (including the set up and take down dates):
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Please state Actual date(s) of the Event(s) only:
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Have all the necessary licences, visas, permits been obtained and have all contractual arrangements been confirmed in writing for the Event(s)?
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If answer is NO to the above question, please give full details:
Has this / have these Event(s) been held (or planned to be held) before?
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If answer to above question is YES, how many years has event been held or planned to be held?
If answer is YES to above question, please provide last 3 event Dates, Venues and Full Addresses and if each event was actually held or not:
Has/have the Event(s) ever suffered a loss?
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If YES, please give full details including Date(s), Loss £ and Cause(s) (NB “Bad Weather” is insufficient)
Have you signed a written tenancy agreement with the Venue(s)
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If NO, please give full details of arrangements
Is/are the Venue(s) currently fully operational and planned to remain so until completion of the Event(s) to be insured?
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If NO to above question, please give full details
If the Event(s) is / are not to be held indoors is / are the Venue(s) currently in suitable condition to hold the Event(s)
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If NO to above question, please give full details
Have all the necessary arrangements for the successful fulfilment of the Event(s) to be insured been made?
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If NO, please give full details of the arrangements
What basis do you wish to insure (please complete as appropriate)
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Cost, Expenses & Commitments SUM INSURED VALUE ($):
Loss of Revenue (i.e. Total Income) SUM INSURED VALUE ($):
Other SUM INSURED VALUE ($) and explain what "Other" basis you wish to insure:
Do(es) the proposed Sum(s) Insured represent the full value of the basis proposed?
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If above answer is NO, please provide full details:
Do(es) the proposed Sum(s) Insured include Artistes Fees / Guarantees?
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If above answer is YES, please provide the amount of such Fees/Guarantees:
If cover is required for Loss of Revenue, can your Revenue figure be substantiated by records from previous Events?
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If above answer is YES, please provide the last 3 years Revenue figures:
Is/are the Event(s) held in conjunction with or dependant upon another event?
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If the above answer is YES, please provide full details
If the proposed performances or event(s) take place at more than one venue, what method of transit will be used by you:
If the proposed performances or event(s) take place at more than one venue, what method of transit will be used for any equipment or items of your essential to the performances or event(s):
Please state the critical factors upon which the successful holding of the Event(s) rely?
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Will the non-appearance of any person(s) cause cancellation or abandonment or curtailment of the Event?
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Details of (all) person(s) to be insured:-
include full first and last name(s), Date of Birth and Describe Participation for each individual to be insured:
Please give full details of any previous non-appearance of the person(s) to be insured.
Has any provision been made for you (or any other person(s) to be insured with you) to have Understudies, Substitutes or Stand-bys?
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If above answer is YES, please provide full details
Is the person(s) to be insured suffering from any physical, psychological or other medical condition?
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If above answer is YES, please provide full details
Is the person(s) to be insured undergoing any form of medical or other treatment?
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If above answer is YES, please provide full details
Is the person(s) to be insured following any prescribed regime medical or otherwise?
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If above answer is YES, please provide full details
What allowance in the itinerary has been made for TRAVEL DELAY:
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What allowance in the itinerary has been made for SET UP TIME:
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What allowance in the itinerary has been made for STAND-BY DATES:
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IMPORTANT NOTICE Please note that failure to disclose all material facts (that is those facts an insurer would regard likely to influence the acceptance or assessment of this proposal) may invalidate the Insurance. If you are in any doubt whether a fact is material you should disclose it. You are advised to keep a record (including copies of letters) of all information supplied to the Insurer for the purpose of entering into the contract of Insurance. A copy of the completed proposal form is available on request for a period of 3 months after it's completion Insurance Premium Tax - General Insurance Business The Finance Act 1994 requires us to levy Insurance Premium Tax at the current rate on most classes of General Insurance Business effected on or after 1st October 1994. For further information, please contact your Insurance Advisor. DECLARATION 1/We declare that the particulars and statements given in this Proposal and the information provided are to the best of my/our knowledge and belief complete and true and 1 am / We are willing to accept the Certificate of Insurance issued by Worldwide Hole ‘N One Ltd on behalf of certain Lloyd’s Underwriters including its terms conditions and exclusions
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Electronic Signature of Applicant
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Date Signed by Applicant
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