Special Event – MySAM Insurance

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33%

What SAM coverage limits do you need?(Required)

Any limit (not specified, just need it to be included)

$50,000

$100,000

$500,000

$1M Each occ / $1M Aggregate

$1M Each occ / $2M Aggregate

$1M Each occ / $3M Aggregate

Other Limit

Enter the SAM limits you are required to have for your special event?(Required)

Do you have a copy of the insurance requirements or contract that ask you to carry the SAM limits you requested above?(Required)

A copy of the insurance requirements or contract requesting SAM limits of $1M/1M or higher will be required by the carrier to approve these limits. Without those requirements, a SAM quote may not be provided. If you don't have the requirements now, you can still proceed with the application, but before a quote is released, you will need to provide a copy of the contract or SAM insurance requirements.

Yes

Upload your insurance requirements here:(Required)

Drop files here or

Max. file size: 512 MB.

Applicant Information

Named Insured:(Required)

This is the name that will be listed on your insurance policy and certificate of insurance. If you have a DBA, state it as follows: for example, ABC Inc DBA XYZ Services.

Entity Type:(Required)

Individual

Partnership

LLC

Corporation

Non-Profit

Other

Entity Type - OTHER - please provide details:(Required)

Physical Address (no PO Box):(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is your mailing address same as above?(Required)

Yes

Mailing Address (if different to primary):(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Person:(Required)

First Last

Phone:(Required)

Email(Required)

Website

Year Business Established:(Required)

Federal ID:

Description of your business operations:(Required)

Please provide a description with a minimum of 10 words.

Underwriting Qualification Questions

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

Yes

Confirm only one event can be covered per policy.(Required)

Yes

Does the event include any of the following? Stunts, Pyrotechnics, Aircrafts, Hazardous Activities, Car Races, Precision Driving, Mechanical Amusement Devices, Film Production, Live Rap or Hip-Hop Performances(Required)

Yes

Any bounce houses or inflatables?(Required)

Yes

Any private armed security? (i.e. armed security that work exclusively for you under your employ)(Required)

Yes

Do you have a Policy in place that Prohibits One-On-One Contact?(Required)

Yes

Insurance History

Any insurance declined or cancelled in the past 3 years? (not applicable in MO)(Required)

Yes

Any prior insurance coverage?(Required)

Yes

Prior Insurance Coverage Details

Carrier(Required)

Policy #(Required)

Expiration Date(Required)

Premium(Required)

Any losses in the past 3 years?(Required)

Yes

Prior Losses Details

Provide Details

Include Policy / Line of Insurance, Date of Loss, Description of the Loss and Amount of Loss.

Event Information

Event Type

(for example Wedding, Anniversary party, Birthday party, Engagement party, Bridal shower, Baby shower, Graduation party, Family reunion, Retirement party, Conference, Seminar, Networking event, Product launch, Company holiday party, Team-building retreat, VIP event, Trade show, Charity gala, Fun run, Walk, Benefit concert, Fundraising dinner, Festival, Parade, Art exhibition, Gallery opening, Farmers' market, Street fair, etc)

Event Name(Required)

Event Description(Required)

Please provide a description with a minimum of 10 words.

Cost/Budget(Required)

Artist/Band (if any)(Required)

if no, enter "None"

Average Daily Spectators(Required)

Average Daily Participants(Required)

Event Dates

Setup Dates(Required)

Event Date(s)(Required)

Tear Down Date(s)(Required)

Venue Details

Name of Venue(Required)

Address(Required)

Event takes place indoors or outdoors(Required)

you can select both indoors and outdoors if applicable

Indoors

Outdoors

OPTIONAL - Concert Information :

Concert Information (applicable only if event includes live music)

Type of Music

Music Decade

Artist(s) Name(s)

OPTIONAL - Vendors :

(complete only if coverage for vendors is required) You are automatically covered for claims arising out of the vendors activities (unless the activities are excluded on the policy). By inputting the information below and providing a schedule subject to underwriter's review, for an additional premium the vendors coverage will be extended to allow for vendors to be covered should they be named in a suit.

# of Exhibitors

# of Non-Food Concessionaires

# of Food Concessionaires

# of Attractions/Performances

Special Event SAM Insurance Application

Special Event Insurance Application with SAM and General Liability