Special Event Insurance Quote INTAKE Form

PRIMARY INSURED INFORMATION

What's the formation type of your business?

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?

What AGENT / BROKER have you talked to at KELLY INSURANCE GROUP?

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

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

The event will take place in the United States or Canada?(Required)

YES

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

Any bounce houses or inflatables? (If yes, certificates of insurance are required)(Required)

YES

Any private armed security? (Private armed security hired by the insured are prohibited)(Required)

YES (not a common answer)

Any claims or losses in the past 3 years?(Required)

YES

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

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

Rented Equipment, Props, Sets, Wardrobe

Is Automobile Liability Insurance Required or Desired?

YES

Do you need comp & collision for Rented / Leased Vehicles?

YES

General Liability Limits

Umbrella / Excess Limits

Is Workers Compensation Coverage Needed

YES

NOT SURE

Would you like Performer / Participant Liability Included?

YES (not typically selected)

NOT SURE

Accident & Medical

Liquor Liability Insurance

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

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

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

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: 100 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

SPECIAL EVENT INSURANCE QUOTE INTAKE FORM

SPECIAL EVENT INSURANCE QUOTE INTAKE FORM