Nicholas Hill Group

Primary Contact Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Fax

(###)

###

####

What is the involvement of the applicant in the event? *

Please select the item that best describes the applicant's role in the event

Organizer

Promoter

Manager

Artist

Sponsor

Other (please provide full details below)

Address of Venue/Hotel/Convention Center *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date Lease Begins (Allowing for installation and dismantling) *

MM

DD

YYYY

Date Lease Ends (Allowing for installation and dismantling) *

MM

DD

YYYY

Open Dates of Event - Beginning *

Date Event opens to public and/or participants

MM

DD

YYYY

Open Dates of Event - Ending *

Date Event is closed to public and/or participants

MM

DD

YYYY

Alternate dates if any - From

MM

DD

YYYY

Alternate dates if any - To

MM

DD

YYYY

Will the event be *

Indoors

Outdoors

Under Temporary Structures

Indoors with some outdoor elements

Are you looking to insure adverse weather for the outdoor portion of an event? *

If yes, please complete the Outdoor Event supplemental application

Yes

No

Type of Event *

Athletic or Sporting Event

Fair or Festival

Music Event

Tradeshow/Conference/Convention

Consumer Show (Art/Antique/Car/Boat/Garden)

Other (please provide full details below)

Do you want to insure Gross Revenue or Expenses? *

Select One

Gross Revenue

Expenses

Does any party other than the applicant have an interest in the Gross Revenue noted above? *

If yes, provide full details below

Yes

No

Do you have a Ticket Refund Policy? *

If yes, provide full details below. If no, then how do you intend to handle refunds and what procedure do you have in place?

Yes

No

Has this event been held before? *

If no, please provide details of the applicant’s experience in organizing events

Yes

No

Is this event open to the public? *

Yes

No

Have all contractual arrangements necessary for the successful fulfillment of the Event been made and confirmed in writing? *

Yes

No

Have all permits, contracts, visas, licenses or the like necessary of the event to be completed successfully been obtained at the time of this application or will they be obtained in good time prior to the start of the event? *

Yes

No

Is the venue under construction or major renovation? *

Yes

No

Is coverage for non-appearance of any person required for the event? *

If yes, please complete the Non-Appearance supplemental application.

Yes

No

Do you wish to purchase terrorism coverage? Please make your selection below *

TRIA Coverage: The event is entitled to coverage in accordance with the US Terrorism Insurance Act (TRIA).

Limited Terrorism extended to include Threat: Such cover is limited to actual acts of terrorism within a 50 mile radius of the event venue and within 50 days prior to commencement of the event extended to include threat of terrorism confirmed in writing by local or national government authorities as posing a real risk of the event.

No coverage: No terrorism coverage required for the event.

Are you aware of any circumstances, currently existing or threatened, that may possibly result in a claim under this insurance? *

If yes, provide details. NOTE: If you become aware of any such circumstances after completing this application, and before the date insurance for the event commences, you must disclose the circumstances to the insurers immediately, as this may affect this insurance.

Yes

No

Have you at any time within the last 5 years had a loss, or circumstances which could have led to a loss which would have been covered by this insurance? *

If yes, provide details

Yes

No

Signing this application and declaration does not bind either the application or the underwriter to provide the insurance. In the event there is any material change in the answers to the questions herein prior to the issuance date of the policy, the application form would be considered inaccurate or incomplete. The applicant will notify the insurer in writing, and, if necessary, any outstanding quotation may be modified or withdrawn. It is agreed that this application and declaration shall be attached to and form part of any policy which may subsequently be issued. To be signed by the Insured The undersigned applicant represents that the statements set forth in this application and its attachments and other materials submitted to the insurer are true and correct. In accepting any quotation provided by result of this proposal request, the insured warrants that all information and answers provided in this application are true and correct. Should an insurance policy be written, this application and any supporting information shall be incorporated into and form the basis of the written insurance policy. The Insured so warrants: *

Yes

No

By typing your name below, you are hereby agreeing to the terms outlined above and providing your personal warranty that all answers and responses that have been provided are true and accurate. Please note: All quotations are subject to the receipt and acceptable review of the application and other underwriting information by the underwriter. *

First Name

Last Name

Date *

MM

DD

YYYY

Primary Contact Name *

First Name

Last Name

Is the venue or any surrounding area that is being used for the event exposed to strong wind, flood or water logging? *

If yes, please provide full detail below

Yes

No

Will the stage or area in which the performers work be covered by a roof and on three sides and will all electrical equipment be protected to comply with industry standards against adverse weather? *

If yes, please provide full details below

Yes

No

The Insured so warrants: *

Yes

No

By typing your name below, you are hereby agreeing to the terms outlined above and providing your personal warranty that all answers and responses that have been provided are true and accurate. Please Note: All quotations are subject to the receipt and acceptable review of the application and other underwriting information by the underwriter. *

First Name

Last Name

Date *

MM

DD

YYYY