Cancellation Event Insurance Form

Phone

Name of Applicant

Applicant Address

Email

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Name of Venue

Venue Address

Is Additional Insured Certificate Needed?

Yes No

Relationship of Additional Insured

Special Certificate Language Needed?

If you have copy of venue insurance requirements or agreement, please upload

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Event Name

Type of Event

Event Start Date

Event End Date

Has this event been held before?

Yes No

Is this event open to the public?

Yes No

Event Cancellation

Please enter the budget information for this event and tick to confirm the basis on which you wish to insure:

a) 100% Gross Revenue (Total Income): * Please note that if the event has not been held before, revenue cover is limited to pre-contracted gross revenue only (money secured in advance of the event such as pre sold tickets)

b) 100% Costs and Expenses:

Which basis do you choose?

A B

Where does this event take place? (Please Tick One) *Predominantly means more than 75% of the event

If outdoors or in temporary structures, is cover required for the effects of adverse weather?

Yes No

If yes, can the event go ahead in continuous moderate rainfall and wind speeds Yes No of up to 30mph/50kmh?

Yes No

Does the event site have any history of flooding or water logging?

Yes No

Has this event ever had any losses as a result of adverse weather, whether insured or not?

Yes No

Will any stages, marquees or temporary structures be covered on three sides and above, Yes No with all electrical equipment protected from weather?

Yes No

Non appearance (Only complete if non-appearance cover is required)

Is non-appearance cover required?

Yes No

Type of non-appearance cover required?

Key speaker (key speakers, presenters, hosts involved in a speaking only role)‎ Individual/Group (performers, groups or entertainers)‎ Simultaneous (Covers 25% of participants* due to Common Cause)‎

Key speaker/Participant/Performer details #1

Key Person's Date of Birth

Is this person a serving/former Head of State/President or member of the Royal Family?

Yes No

Key speaker/Participant/Performer details #2

Key Person's Date of Birth

Is this person a serving/former Head of State/President or member of the Royal Family?

Yes No

Are there 20 or more participants* in total?

Yes No

Will all contractual arrangements necessary for the successful fulfillment of each event be made and confirmed in writing in a prudent timely manner prior to the start of the event?

Yes No

Event cancellation

Has any event to be insured had any incidents that could have resulted or did result in a loss which would have been covered under this Insurance during the past 5 years?

Yes No

Are you aware of any matter, fact, circumstance or incident existing or threatened that could possibly affect any event and might result in a claim under the proposed Insurance?

Yes No

Additional information

Please provide any additional information to support your application:

Declaration

To the best of Your knowledge and belief and having diligently made all necessary inquiries, the information provided in connection with this proposal, whether in Your own hand or not, is true and You have not withheld any material facts. You understand that non-disclosure or misrepresentation of a material fact will entitle Us to void the Insurance. NOTE: * A material fact is one likely to influence acceptance or assessment of this Proposal by Us. If You are in any doubt as to what constitutes a material fact You should consult Your Broker. It is understood that the acceptance of this non binding indication does not bind You to complete or Us to accept this Insurance, but You agree that, should a contract of insurance be concluded, this non binding indication and any supporting information shall be incorporated into and form the basis of the contract. I/we the Proposer(s) accept these conditions as the Proposed Assured or agent of the Proposed Assured and that any subsequent insurance will become null and void if any of the foregoing conditions are breached.

Yes No

Signature

I/We declare that the information provided above and in all appending sections is true to the best of My/Our knowledge.

Electronic signature

Clear

Signers Printed Name

Signers Position

Date Signed