ENTERTAINMENT SERVICES INTAKE FORM

ENTERTAINMENT SERVICES INSURANCE INTAKE FORM

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BUSINESS INFORMATION

Name of Applicant ( the Name You Use to CONDUCT BUSINESS )

Form of Business

LLC

SOLE PROPRIETOR / INDIVIDUAL

S CORPORATION

C CORPORATION

NON PROFIT

PARTNERSHIP

JOINT VENTURE

LLP

What's the Owner's FULL INDIVIDUAL LEGAL Name

Is this a New Business?

YES

What Year was this Business Started?

Has there been and Changes in Ownership or Management?

YES

How many Years has the Business been under New Management / Ownership?

Name of Contact Person

Email Address

Phone Number (mobile preferred)

Types of Insurance Coverage Needed

GENERAL LIABLIITY

RENTED EQUIPMENT INSURANCE ( Rented from Others )

OWNED EQUIPMENT INSURANCE

COMMERCIAL AUTOMOBILE LIABILITY

RENTED VEHICLE AUTO INSURANCE

HIRED & NON-OWNED AUTO LIABILITY

WORKERS COMPENSATION

EXCESS / UMBRELLA LIABILITY

EMPLOYMENT PRACTICES LIABILITY

CYBER / DATA BREACH LIABILITY

BUILDING COVERAGE

OFFICE RELATED PROPERTY

In there any Current Insurance in Place for Your Business?

YES

Are there any Specific Insurance Requirements that are REQUIRED?

YES

MAILING ADDRESS

Street Address

City

State

Zip Code

Do you have any other Locations?

Including Warehousing Locations, Garaging Locations, Office Locations, etc...

YES

LOCATION ADDRESS (Street, City, State, ZIP)

What are Your Guesstimated Total Annual Revenues?

Check the Activities that Best Describe your Business

AUDIO / VISUAL / LIGHTING COMPANIES

EVENT DESIGN & CONSULTING

LED WALLS

SOUNDBOARD OPERATIONS

RENTING EQUIPMENT from OTHERS

RENTING EQUIPMENT to OTHERS

EQUIPMENT RENTAL HOUSE

EQUIPMENT SALES

EVENT PLANNING

STAGECRAFTING ( Building Stages )

MOBILE STAGES & STAGE TRAILERS

MOBILE LED WALLS & LED TRAILERS

PROMOTERS & ORGANIZERS

PYROTECHNICS & FIREWORKS

MISCELLANEOUS STAGING EFFECTS

TRUSS INSTALLATION

STAGE CREW & STAGEHANDS

LASER ARRAYS

AERIAL PERFORMERS

EQUIPMENT CLIMBERS

MOBILE EQUIPMENT RIGGING

DRONE / UAV OPERATION ( Owned Drones )

LIGHT ENTERTAINMENT RIGGING ( Heights 30 Feet or Less ) )

HEAVY ENTERTAINMENT RIGGING ( Heights of 50'+ )

RIGGING that INCLUDES PERSONNEL CLIMBING to SERVICE / INSTALL EQUIPMENT

check all that apply

Height of Typical Work Performed

MOST WORK PERFORMED FROM GROUND

UNDER 10 FEET

BETWEEN 10 FEET & 30 FEET

BETWEEN 30 FEET & 50 FEET

BETWEEN 50 FEET & 100 FEET

OVER 100 FEET

Do any Subsidiaries need to be Included?

YES

SUBSIDIARY INFORMATION

List the Names for All Subsidiary Organizations that need Included

Describe the Activities of all Subsidiaries

Do You have Employees?

YES

OWNERS ARE THE ONLY WORKERS

Do You use Sub Contractors?

YES

OWNER / MANAGER / MEMBER INFORMATION & EXPERIENCE

How Many OWNERS does this Business Have?

Describe Experience of OWNERS, MEMBERS, or MANAGERS

How Many Years of Experience do the OWNERS, MEMBERS, or MANAGERS have in this Field?

1 YEAR

2 - 4 YEARS

5 - 10 YEARS

10+ YEARS EXPERIENCE

LITTLE to NO EXPERIENCE

Does Your Business, its OWNERS, MEMBERS or MANAGERS, hold any Safety Certifications or any Memberships in Safety Organizations?

YES

What Safety Certifications or Memberships do the Managers / Members / or Owners Have?

OSHA 10

EVENT SAFETY ALLIANCE ( ESA )

EVENT SAFETY ACCESS TRAINING

MOTOR VEHICLE DEFESNSIVE DRIVING TRAINING

CERTIFICATE in EVENT SAFETY

AV TECH CERTIFICATIONS

OTHERS

ENTERTAINMENT TECHNICIAN CERTIFICATION PROGRAM - ETCP

INTERNATIONAL ALLIANCE of THEATRICAL STAGE EMPLOYEES - IATSE

NO SAFETY CERTIFICATIONS

Detail any 'OTHER' Safety Certifications Here

EMPLOYEE INFORMATION

WHAT TYPES of EMPLOYEES DO YOU HAVE?

CLERICAL / OFFICE STAFF

SALES STAFF

TECHNICIANS & INSTALLERS

PERFORMERS / ARTISTS

STAGE CREW & STAGEHANDS

ALL OTHER TYPES OF ENTERTAINMENT RELATED EMPLOYEES

Describe Your EMPLOYEES ACTIVITIES NOT LISTED ABOVE

On Average, How Many Years of Experience do your Employees have?

1 YEAR

2 - 4 YEARS

5 - 10 YEARS

10+ YEARS EXPERIENCE

LITTLE to NO EXPERIENCE

Do any of Your Employees hold any Safety Certifications or any Memberships in Safety Organizations? ?

YES

What Safety Certifications or Memberships do some of Your Employees Have?

OSHA 10

EVENT SAFETY ALLIANCE ( ESA )

EVENT SAFETY ACCESS TRAINING

MOTOR VEHICLE DEFESNSIVE DRIVING TRAINING

CERTIFICATE in EVENT SAFETY

AV TECH CERTIFICATIONS

OTHERS

ENTERTAINMENT TECHNICIAN CERTIFICATION PROGRAM - ETCP

INTERNATIONAL ALLIANCE of THEATRICAL STAGE EMPLOYEES - IATSE

Check All that Apply Regarding Hiring Employees

BACKGROUND CHECKS ARE PERFORMED

DRUG SCREENING

MVR & LICENSE CHECKS

CREDIT CHECKS

REFERENCE CHECKS

FORMAL APPLICATION / HIRING PRACTICES

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Clerical / Office Staff Payroll for Next 12 Months ( do not include Owner Pay or SUB CONTRACTOR COSTS )

Guesstimate is okay...

Total Number of Clerical / Office Staff ( do not include Owner Pay or SUB CONTRACTOR COSTS )

Guesstimate is okay...

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Sales Staff Payroll for Next 12 Months ( do not include Owner Pay or SUB CONTRACTOR COSTS )

Guesstimate is okay...

Total Number of Sales Staff ( do not include Owner Pay or SUB CONTRACTOR COSTS )

Guesstimate is okay...

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Technician / Installers Payroll for Next 12 Months ( do not include Owner Pay or SUB CONTRACTOR COSTS )

Guesstimate is okay...

Total Number of Technician / Installers ( do not include Owner Pay or SUB CONTRACTOR COSTS )

Guesstimate is okay...

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Describe the Activities of PERFORMERS / ARTISTS

PERFORMER / ARTIST Employee Payroll for Next 12 Months ( do not include Owner Pay or SUB CONTRACTOR COSTS )

Guesstimate is okay...

Total Number of Employee PERFORMERS / ARTISTS ( do not include Owner Pay or SUB CONTRACTOR COSTS )

Guesstimate is okay...

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STAGE CREW / STAGE HAND Employee Payroll for Next 12 Months ( do not include Owner Pay or SUB CONTRACTOR COSTS )

Guesstimate is okay...

Total Number of Employee STAGE CREW / STAGE HAND Employees ( do not include Owner Pay or SUB CONTRACTOR COSTS )

Guesstimate is okay...

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What is the 'OTHER' Activities Payroll for Next 12 Months ( do not include Owner Pay or SUB CONTRACTOR COSTS )

Guesstimate is okay...

Total Number of 'OTHER' Employees ( do not include Owner Pay or SUB CONTRACTOR COSTS )

Guesstimate is okay...

SUB CONTRACTOR INFORMATION

Estimated TOTAL Annual cost of All SUB CONTRACTORS

Guesstimate is okay...

DESCRIBE WORK COMPLETED BY SUB CONTRACTORS	GUESSTIMATE ANNUAL SUB CONTRACTOR COST FOR THIS WORK	SAFETY CERTIFICATIONS	YEARS of EXPERIENCE

Check All that Apply Regarding Your use of SUB CONTRACTORS

WE USE A SERVICE AGREEMENT WITH ALL SUB CONTRACTORS

WE GET CERTIFICATES OF INSURANCE FROM ALL SUB CONTRACTORS

Is Work Performed

INDOORS

OUTDOORS

BOTH

Guesstimated Number of Events during the Year where you Perform Services INDOORS

Guesstimated Number of Events during the Year where you Perform Services OUTDOORS

When You Perform Work OUTDOORS, check all Weather Safety Precautions Followed

INCLEMENT WEATHER ACTION PLANS

WEATHER MONITORING SERVICES

WE ARE NOT RESPONSIBLE FOR MONITORING WEATHER

OTHER

Describe all other Weather Safety Precautions Followed

Does Your Business...

ENGAGE in PERMANENT INSTALLATIONS

ENGAGE in TEMPORARY INSTALLATIONS

BOTH

What Percentage of Work includes PERMANENT INSTALLS?

What Percentage of Work includes TEMPORARY INSTALLS?

RIGGING SECTION

Describe the items typically Hoisted, Lowered, Rigged, and/or 'ON-HOOK'

Describe in Detail the Equipment Used for Lifting

Describe in Detail what types of Guy Wires are Used and what/if Weights are Integrated into the System

What is the MAXIMUM Value for any Item Hoisted, Lowered, Rigged, and/or 'ON-HOOK'

What percentage of the Time is there a CERTIFIED TECHNICIAN Supervising the Work?

What percentage of the Time is does a CERTIFIED TECHNICIAN Complete the Work?

Are Guy Wires Ever Used?

YES

Describe in Detail what types of Guy Wires are Used

Are Counter-Weights Ever Used?

YES

Please describe in Detail how Counter-Weights are being Used

AERIAL PERFORMERS & EQUIPMENT CLIMBERS

For those that Perform Aerially or Climb to Install or Service Equipment, what is the MINIMUM HEIGHT?

For those that Perform Aerially or Climb to Install or Service Equipment, what is the MAXIUM HEIGHT?

Describe in Detail the Types of Equipment Used to HARNESS & HOLD AERIAL PERFORMERSs or CLIMBERS

Are Guy Wires Ever Used?

YES

Describe in Detail what types of Guy Wires are Used

Are Counter-Weights Ever Used?

YES

Please describe in Detail how Counter-Weights are being Used

STAGE BUILDING / STAGE CRAFTING SECTION

What are the Average Dimensions of the Stages Being Built?

Does an Engineer 'Sign-Off' on Staging Installations?

YES

NOT APPLICABLE

Are Guy Wires Ever Used?

YES

Describe in Detail what types of Guy Wires are Used

Are Counter-Weights Ever Used?

YES

Please describe in Detail how Counter-Weights are being Used

Do You Use, Own, or handle/install Any Equipment?

Check all that Apply

NO OWNED EQUIPMENT

USE OTHERS EQUIPMENT ( without a Rental Agreement )

WE OWN EQUIPMENT

WE RENT EQUIPMENT FROM OTHERS

Describe How ALL Equipment is Used

What Types of Equipment are Typically Used?

INLAND MARINE / EQUIPMENT INSURANCE SECTION

Describe how Your Owned Equipment is Inventoried

Describe how All Equipment is Kept Safe while Stored or On-Site

Does your Company Own any Specialized Equipment, or any Equipment where a singular Item is Valued at over $25,000?

Include any items that are hard to Repair or Replace

YES

EQUIPMENT DESCRIPTION	HOW MANY OF THESE DO YOU HAVE	SERIAL NUMBER (if applicable)	APPROXIMATE MODEL YEAR	APPROXIMATE VALUE

Does your Company Own more than $100,000 worth of Equipment

All Types of Owned Equipment

YES

RENTING EQUIPMENT TO OTHERS

What is the MAXIMUM Value of All Equipment Rented TO Others

MAXIMUM Value Per Rental of all Equipment

When you Rent Equipment to Others, Check All Applicable Items...

WE COLLECT CERTIFICATES of INSURANCE

THE RENTAL AGREEMENT HOLDS THE PERSON or BUSINESS FULLY RESPONSIBLE

THE PERSON or BUSINESS HOLDS YOU HARMLESS

YOU RUN A CREDIT CARD FOR ALL RENTALS

THE PERSON or BUSINESS TRANSPORTS THE EQUIPMENT

REFERENCES ARE CHECKED

CERTIFICATE OF INSURANCE VERIFICATION

NO SAME DAY PICKUPS

YOU COLLECT IDENTIFICATION FROM THE RENTER

Guesstimated Total Annual Revenue from Renting Equipment to Others?

In this Total. also Include Revenue from You or Your Employees or Sub Contractors Setting Up Your Owned Equipment for Others

RENTING EQUIPMENT FROM OTHERS

Describe the Equipment You RENT from OTHERS

Does your Company Rent any Specialized Equipment, or any Equipment where a singular Item is Valued at over $25,000?

Include any items that are hard to Repair or Replace

YES

Describe this Equipment and the Corresponding Value

What is the MAXIMUM Value of All Equipment Rented FROM Others

MAXIMUM Value Per Rental of all Equipment

SAFEGUARDING OF EQUIPMENT

Check All Safe Keeping Practices for All Equipment

SECURITY ALARM ( Central Station Reporting )

FIRE ALARM ( Central Station Reporting )

CCTV or INTERNET CAMERAS

SPRINKLER SYSTEMS

NEVER LEFT IN A VEHICLE UNATTENDED

TEMPERATURE CONTROLLED ENVIRONMENTS

EQUIPMENT KEPT AWAY FROM WATER SOURCES & PIPES/HOSES

BACK-UP GENERATORS IN PLACE

WATER DETECTION DEVICES

FENCED or GATED ENTRANCE

LOCATION OR GPS MONITORING

OTHER

Describe 'OTHER' Safeguarding Methods

Do You PRE-INSPECT / TEST Equipment Prior to Use?

YES

OTHER

Describe Here

VEHICLE USAGE

Does Your Business Own or plan on Renting any Vehicles?

WE OWN A VEHICLE or MULTIPLE VEHICLES

WE RENT VEHICLES from OTHERS

NO VEHICLES ARE USED FOR BUSINESS PURPOSES

Would You Like an AUTO Insurance Quote for Your OWNED VEHICLES?

YES

VEHICLE USE INFORMATION

Describe where all Vehicles are usually Kept or Stored

What types of Vehicles are Usually Rented from Others?

OWNED VEHICLE INFORMATION

YEAR	MAKE	MODEL	VIN	COST NEW	COST OF ATTACHED EQUIPMENT

DRIVER NAME	DATE OF BIRTH	LICENSE STATE	LICENSE NUMBER	CDL?

RENTED VEHICLE INFORMATION

What's the Maximum Number of Rented Vehicles You would have at ANY ONE TIME?

What's the Average Value per any One RENTED VEHICLE?

What would You Guesstimate the Annual Cost would be to RENT Vehicles?

Do You have Any EXPOSURES in the Following Areas?

WELDING, SOLDERING, COOKING, ETC.

FLAMMABLE GASSES or COMPRESSED GASSES

PYROTECHNICS or FIREWORKS?

MANUFACTURING of PRODUCTS

SALES of REPACKAGED PRODUCTS

CARPENTRY or CUSTOM BUILDS

NONE OF THESE

Describe in Detail the PYROTECHNICS / FIREWORKS SERVICES

Describe in Detail the CARPENTRY & CUSTOM BUILD SERVICES You Provide

Any Previous Claims attributable to Your Business in the Past 5 Years?

Whether Insured or Not

YES

Do You expect Your REVENUE to ....

INCREASE SOMEWHAT NEXT YEAR

INCREASE DRAMATICALLY NEXT YEAR

DECLINE SOMEWHAT NEXT YEAR

DECLINE DRAMATICALLY NEXT YEAR

LIKELY STAY THE SAME or SIMILAR

Please upload a List or Inventory Sheet of All of Your Owned Equipment ( this MAY be Required by the UNDERWRITER )

PDF, Excel, CSV ( or email inventory sheet to forms@kelins.com )

Max. file size: 16 MB.

Please Upload a Sample of the AGREEMENT You Use with Your SUB CONTRACTORS

This helps our UNDERWRITERS provide the Best Possible Pricing

Max. file size: 16 MB.

Please Upload a SAMPLE Agreement You Use when You RENT EQUIPMENT to OTHERS

This helps our UNDERWRITERS provide the Best Possible Pricing

Max. file size: 16 MB.

Please Upload a Biography or Resume of the Key Person Involved in PYROTECHNICS / FIREWORKS

This is required by the UNDERWRITERS

Max. file size: 16 MB.

ABOUT THE CERTIFICATE of INSURANCE REQUIREMENTS YOU ARE REQUIRED TO HOLD

Would You like to UPLOAD or COPY and PASTE the CERTIFICATE REQUIREMENTS?

UPLOAD

COPY & PASTE

CERTIFICATE REQUIREMENTS

for upload

Max. file size: 16 MB.

CERTIFICATE REQUIREMENTS?

copy and paste

Section Break

If Possible, Please Attached Copies of All Pertinent Current Policy Documents

This helps our UNDERWRITERS provide the Best Possible Pricing

Drop files here or

Max. file size: 16 MB.

Please Upload Copies of ALL POLICY LOSS RUNS

3 YEARS MINIMUM NEEDED, but 5 is PREFERRED. This helps our UNDERWRITERS provide the Best Possible Pricing

Drop files here or

Max. file size: 16 MB.