AGENTS INSURANCE MARKETS, INC.
P. O. Box 71360
Richmond, VA 23255-1360
800-627-0505 (Phone)/804-285-4945(Fax)
Special Event Application
Complete section(s) applicable to the type of event being held. Application must be signed and dated by the applicant.
Applicant's Name ___ VAbP. Agent _Ball-Martin Insurance Agency, Inc.
Applicant Mailing Address L2or /Z2227. Applicant's Phone Number Hie — 779 ¢
Kichoerty) Lf) Web Address ww. vady. ere
2224] ion Contact 2
Proposed Policy Period [21 to 1/2 Phone Number for Contact
Applicant is [] Individual C] Partnership £) Corporation © Joint Venture 4 Other Alasprcke-
Event Location #1 y Lr 2 Lie.
Event Location #2
Event Location #3
UNDERWRITING INFORMATION
1. Event Dates Natale 2), Zep. }
Description of Event (Attach Copy of flyer or brochure)
2. Estimated attendance per day [72 sot nena TE : seers. TOtal for all days event is held_Z_
Gross Sales $_. 5,097
3. Food or beverages Sold or served by applicant? ....... — ..O Yes W No
If yes, provide details. Te ge wok be AB Dab
4. Alcoholic ges on premises? JM Yes CNo
If yes, are they served by [] applicant or x other? Is liquor liability coverage in place? ............... mal Yes [] No
5. Seating arrangements — Describe (.€., permanent, portable, bleachers, chairs, etc.)
Chaise 2p Loud she in He] La, Locate
If portable, who does the erection?
6. Setup ~ Describe all exposures (i.2., booths, stages, electrical, Spat anes etc.)
7. Security ~ Describe (ie., guards - unarmed vs. armed, dogs, off-duty police, etc) HA
If guards are used, do they have their own i 2. a cat OlYes C1No
8. Parking facilities ....... sous BY Yes £1 No
Operated by: [] Applicant 4X Others If others, do they have their own insurance? oeeeeeccccssous O Yes 1) No
Is parking area Pa Paved [J Dirt O Other (describe)
9. Medical emergencies ~ describe how an emergency will be handled: Lal) SC/A
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UNDERWRITING INFORMATION (Continued)
10. Are certificates of insurance required from all DOSIBHONS? scccscenonmagenerren sacs . ™ Yes [] No
11. Does the applicant use any mobile equi ? O Yes I No
If yes, describe and give details of how it is used.
ANIMAL EXPOSURE
1. Are there animal rides?....1] Yes Jeo If yes, are animals hand lead? O Yes O1No
List the types of animals
Describe area where rides are given (arena, roped off area, etc.)
Is safety used? O Yes (No
2. Is there a petting zoo?.......] Yes Jaro If yes, describe.
List the types of animals
How is it set up (fenced area, etc.)?
Is the area supervised? . (O Yes 1 No
AMUSEMENT DEVICES - KIDDIE TYPE
1, Provide a complete list of equipment. WA
2. Is applicant properly licensed to operate 2 (O Yes (No
3. Are the rides supervised at all times? O Yes (No
4. Does the vendor or subcontractor operate Kiddie rides?
AMUSEMENT DEVICES - OTHER THAN KIDDIE TYPE
Operator must have insurance and provide a certificate of insurance with limits and
requested on this application.
DEMOLITION DERBY, MUD BOGS AND TRACTOR PULLS
coverage at least equal to those
Provide description of facility (Attach diagram on separate sheet) including type of protection used to protect the spectators from
flying debris, 9, barriers to keep vehicles a safe distance from spectators, etc.
”,
DOG RACES, HORSE RACES, RODEOS AND HORSE SHOWS
1. Provide description of facility (Attach diagram on separate sheet)
MWA
2. Are spectators allowed in any area where animals are kept when not performing?
3. Do livestock contractors have their own insurance?
see] Yes [No
4. Is seating at least ten (10) feet from the arena?
O Yes 1 No
O Yes C1 No
FAIRS AND CARNIVALS
Provide complete via of event (Attach diagram on separate sheet indicating location of each exhibit, booth, ride, event, etc.)
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Page 2 of 4
Wa
FIREWORKS EXHIBITION — SPONSOR'S RISK ONLY
of
1. Pyrotechnicians must be licensed, have i and provide with limits and coverage at least
equal to those req} on this a OYes (No
2. Are volunteers used to perform any duties at the exhibition? O Yes C1 No
3. Spectators must be at least one hundred fifty (150) feet from where fireworks are being set off. Describe crowd controls
used to maintain this distance.
4. Describe the duties performed by volunteers.
MUSICAL CONCERTS
1. Name of performer(s) and type of music My
2. Do they have their own insurance? O Yes T1No
3. Describe seating, i.e., bleachers, grass, folding chairs, etc.
4. Is seating assigned? (O Yes No
5. Type of venue. D indoor O outdoor
If outdoors, if facility designed to accommodate this type of @VEME? .oo..ssscssssssonsnssnvseesraasessee .O Yes ONo
PARADES - SPECTATOR LIABILITY ONLY
1. Provide complete deserpion of parade including crowd control (Attach diagram of route and spectator areas on separate sheet.)
ALA
2. Provide number and type of floats
3. Are there any animals in the parade? . sol] Yes 1) No
If yes, describe.
4. Are participants required to have their own AP scossneees ‘O Yes C1 No
LIMITS - GENERAL LIABILITY (PER OCCURRENCE)
GENERAL AGGREGATE (OTHER THAN PRODUCTS/COMPLETED Operations) $_2,000,000
Propucts & COMPLETED OPERATIONS AGGREGATE $
PERSONAL & ADVERTISING INJURY (ANY ONE PERSON oR O} $
EAcH OccuRRENCE $_1,000,000
DAMAGE To PREMISES RENTED To You (ANY ONE PREMISES) $
MEDICAL EXPENSE (ANY ONE PERSON) $
CERTIFICATE RECIPIENTS / ADDITIONAL INTERESTS
RELATIONSHIP ADDITIONAL
IF
Name Anp Appress TO APPLICANT INSURED CERTIFICATE
Rich Charlottesville Hotel dba Double Tree by Hilton Charlotesville & Greenwood
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i o
oO oO
Oo oO
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PRIOR CARRIER HISTORY & LOSS INFORMATION
PRIOR CARRIERS (LAST THREE YEARS):
YEAR CaRRIER Poticy NUMBER Limits PREMIUM
None
Loss History (Last Five Years)
Date oF Loss Type oF Loss DEscRIPTION OF Loss Amount PAID RESERVE
WA None
Has the applicant been cancelled or non-renewed in the last three years? ...scsssssesseeasneee
coven] Yes BJ No
If yes, Explain.
This application shall not be binding unless and until confirmation by the Company or its duly appointed representatives has
been given, and that a policy shall be issued and a payment shall be made, and then only as of the commencement date of
said policy and in accordance with all terms thereof. The said applicant hereby covenants and agrees that the foregoing
statements and answers are a full and true statement of all the facts and circumstances with regard to the risk to be insured,
and the same are hereby made the basis and conditions of the insurance and a warranty on the part of the Insured.
(XC ZLE- Ye
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Producer's Signature Date Applicant's Signature Date
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning character,
general reputation, personal characteristics, and mode of living. Upon written request, additional information as to the nature
and scope of the report, if one is made, will be provided.
FRAUD STATEMENT
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
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