Event Cancellation/Non-Appearance Application

EVENT CANCELLATION/NON-APPEARANCE APPLICATION

Producer Company: Nicholas Hill Group, Inc., Producer Name: Ryan E. Hill, Telephone: 719-630-1397, Email: info@nicholashillgroup.com, Mailing Address: 1765 South 8th Street, suite 800, Colorado Springs, CO 80905

1. Name of Person or Organization applying for Insurance:

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

2. What is the usual business of the Applicant(s) and how long engaged therein?

3. Name of the Event?

4. Has this/have these performances(s) or event(s) been held before?

Yes
No

If so, how often?

5. What is/are the involvement(s) of the Applicant(s) in performance(s) or event(s) and what is/are the experience(s) of the Applicant(s) in this capacity?

6. Is/are the performances(s) or event(s) part of a larger production, promotion, series or tour?

Yes
No

If yes, please state which below:

7. If the proposed event is a tour, what will be the method of transport used by insured person(s)?

Equipment?

8. Event Dates(s)/Times(s): Event Name:__________________ From:_____________________ To:____________________

If the event is longer than five days, please submit additional dates and times below. Please include a schedule of the events planned for the Event

9. What allowance in the itinerary has been made for Travel Delay?________________ Set up time?___________________ Stand-by dates? ________________

10. Is the event held:

Indoor?
Outdoor?
Under Canvas
Other?

If other, please specify below:

11. Name of venue where the event will be held: *(see additional requirement at the bottom of this form)

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

12. Will the event venue require construction work?

Yes
No

If yes, please provide details below:

13. Will adverse weather conditions preclude the fulfillment of the event

Yes
No

If yes, please detail the weather conditions which would cause the event to be canceled below:

14. Would the non-appearance of any individual, group, act, team, etc. preclude the fulfillment of the event?

Yes
No

If yes, please provide details below:

QUESTIONS 15 - 18 ARE FOR NON-APPEARANCE COVERAGE ONLY

15. Details of (all) person(s) to be insured. Name(s), age(s) and participation, (only for non-appearance coverage):

16. Has any person to be insured any history of non-appearance, (only for non-appearance coverage):

Yes
No

If yes, please provide details below:

17. Has any provision been made for Understudies or Substitutes, (only for non-appearance coverage)?

Yes
No

If yes, please provide details below:

18. Is/are the person(s) to be insured suffering from any physical, psychological or other medical conditions? Is/are the person(s) to be insured undergoing any form of medical or other treatment or following any prescribed medical regime?

Yes
No

(questions pertain only to non-appearance coverage). If yes please provide full details below:

19. Have all necessary arrangements for the successful fulfillment of the performance(s) or event(s) to be insured been made?

Yes
No

If no, please provide details below:

20. Hae all necessary licenses, visas, and/or permits been obtained and have all contractual arrangements been confirmed in writing?

Yes
No

If no, please provide details below:

21. Please complete both of the following categories (see definitions listed below) and please indicate which amount is to be insured:

Please list the justification of the Sum Insured below, explaining how the dollar amount provided was calculated. If possible, please include the budget for the event.

DEFINITIONS OF CATEGORIES

A. GROSS REVENUE: All monies paid or payable to the Applicant from every source arising out of the Event

B. EXPENSES: The total of all costs and charges incurred by the Applicant for, and in connection with, the planning, preparation, and staging of the Event.

22. Do these sums represent the full extent of your financial responsibilities?

Yes
No

If no, please provide details below:

23. If the performance(s) or event(s) has/have been held before under the present management or any other, has there ever been a loss?

Yes
No

If yes, please provide full details below:

24. Has the Applicant sustained any loss or damage during the last five years which would have been covered by this type of insurance had it been in force?

Yes
No

If yes, please provide full details below:

25. Has the Applicant had similiar insurance, (as applied for herein), declined, canceled or renewal refused?

Yes
No

If yes, please provide details below:

26. Are there any other material facts or items of information with regard to the proposed performance(s) or event(s) which should be disclosed? (A material fact is one likely to influence acceptance or assessment of this proposal by Underwriters)?

Yes
No

If yes, please provide full details below:

DECLARATION

To the best of my knowledge and belief the information provided in this application, whether in my own hand or not, is true and I have not withheld any material facts.

I understand that non-disclosures or misrepresentation of material fact will entitile the company to void the insurance.

I understand that signing this Application does not bind me to complete the insurance but agree that should an insurance policy be issued, this Application and the statements made therein shall form the basis of the insurance policy.

Name

First Name Last Name

TITLE:

DATE:

PHONE NUMBER:

Email Address