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SPECIAL EVENT INSURANCE QUOTE INTAKE FORM
SPECIAL EVENT INSURANCE QUOTE INTAKE FORM
Step
1
of
6
16%
PRIMARY INSURED INFORMATION
What's the formation type of your business?
Corporation
LLC
Individual / Sole Proprietor
Partnership
Joint-Venture
Non-Profit
Trust
What's the name of your LLC?
What's the name of your Corporation?
What's the full legal name of the individual?
What's the name of your Non-Profit?
What's the name of your Partnership?
What are the names of the businesses or individuals in the Joint Venture?
What's the name of the Trust?
MAILING ADDRESS (no P.O. Boxes) : This is your address, not the venue/event address
Street Address
City
State
Zip
PRIMARY CONTACT INFORMATION
First Name
Last Name
Phone Number
Email Address
Is the Primary Contact Listed Above an Owner, Executive, or Partner?
YES
NO
Please list the name of at least one Owner, Executive, or Partner
UNDERWRITING QUESTIONS
Does the event include any of the following? Stunts, Pyrotechnics, Aircrafts, Hazardous Activities, Car Races, Precision Driving, Mechanical Amusement Devices, Film Production
(Required)
YES
NO
The event will take place in the United States or Canada?
(Required)
YES
NO
Answer 'YES' to Confirm only one event can be covered per policy.
(Required)
YES - this can include a one day event or a multi-day event
NO
Any bounce houses or inflatables? (If yes, certificates of insurance are required)
(Required)
YES
NO
Any private armed security? (Private armed security hired by the insured are prohibited)
(Required)
YES (not a common answer)
NO
Any claims or losses in the past 3 years?
(Required)
YES
NO
Please describe any losses and the total amount paid
EVENT DETAILS
Describe the Event
What's the name of the Event?
What's the total cost/budget for the Event?
Will this event feature a Live Performance by an Artist or Band
YES
NO
List all Artists or Bands that will be performing
How many total Attendees?
How many total Performers & Personnel?
Will this Event be Indoor or Outdoor?
INDOOR
OUTDOOR
Is this Event
ONE DAY ONLY
MULTIPLE DAYS
What Date will the Event take place?
List All Days this Event will take place
EVENT VENUE DETAILS
What's the Name of the Venue/Space where the Event is being held?
Street Address of Venue
City
State
Zip Code
COVERAGE OPTIONS
Owned Equipment, Props, Sets, Wardrobe
NOT NEEDED
NOT SURE
$10,000
$25,000
$50,000
$75,000
$100,000
$150,000
$200,000
$250,000
$300,000
$350,000
$400,000
$500,000
$600,000
$750,000
$1,000,000
$1,250,000
$1,500,000
$2,000,000
$2,500,000
$3,000,000
Rented Equipment, Props, Sets, Wardrobe
NOT NEEDED
NOT SURE
$10,000
$25,000
$50,000
$75,000
$100,000
$150,000
$200,000
$250,000
$300,000
$350,000
$400,000
$500,000
$600,000
$750,000
$1,000,000
$1,250,000
$1,500,000
$2,000,000
$2,500,000
$3,000,000
Is Automobile Liability Insurance Required or Desired?
YES
NO
Do you need comp & collision for Rented / Leased Vehicles?
YES
NO
General Liability Limits
$1,000,000 / $2,000,000
$2,000,000 / $2,000,000
$2,000,000 / $3,000,000
$3,000,000 / $3,000,000
$4,000,000 / $5,000,000
$5,000,000 / $5,000,000
$10,000,000
Umbrella / Excess Limits
NOT NEEDED
NOT SURE
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
$6,000,000
$7,000,000
$8,000,000
$9,000,000
$10,000,000
Is Workers Compensation Coverage Needed
YES
NO
NOT SURE
Would you like Performer / Participant Liability Included?
YES (not typically selected)
NO
NOT SURE
Accident & Medical
COVERAGE NOT NEEDED
COVERAGE NEEDED FOR PERFORMERS / ARTISTS / PARTICIPANTS ONLY
COVERAGE NEEDED FOR ATTENDEES & SPECTATORS
COVERAGE NEEDED FOR BOTH
NOT SURE
Liquor Liability Insurance
NOT NEEDED
HOST LIQUOR LIABILITY ONLY
FULL LIQUOR LIABILITY
NOT SURE
Is Vendor Liability Needed?
Select All that Apply
Not Needed (this option is most common)
Exhibitor Coverage Needed
Food or Non-Food Concessionaires Coverage Needed
Performer/Attraction Coverage Needed
NOT SURE
# of Exhibitors Needing Coverage
# of Concessionaires Needing Coverage
# of Performers Needing Coverage
WORKERS COMPENSATION INFORMATION
Do you have Employees?
YES
NO EMPLOYEES, BUT WORKERS COMPENSATION IS REQUIRED
NO EMPLOYEES & WORKERS COMPENSATION IS NOT NEEDED
How many Full Time Employees?
Full Time Employee Guesstimated Total Payroll
How many Part Time Employees?
Part Time Employee Guesstimated Total Payroll
Are you using a Payroll Company?
YES
NO
What's the name of the Payroll Company?
Would you like to enter your FEIN or TAX ID Number?
Not required if you just need a quote
YES
NO
I DON'T HAVE AN FEIN / TAX ID NUMBER
What's your TAX ID / FEIN NUMBER?
CERTIFICATE & ENDORSEMENT REQUIREMENTS
Is the Event Venue Requiring you to carry specific insurance limits?
YES
NO
NOT SURE
How would you like to provide the certificate requirements?
Copy and Paste the Wording Required in the next Field
Attach a file showing the requirements
Email the Requirements Separately (email to forms@kelins.com)
Limits of Insurance selected on Previous Pages meets the Requirements
Copy and Paste the Wording Required here
Upload a copy of the Certificate Here
Max. file size: 16 MB.
Do you need any of the following for the Certificates of Insurance?
Additional Insureds
Waivers of Subrogation
Primary and Non Contributory Wording
Certificates of Insurance for Government Entities, Cities, or National Parks
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