Nicholas Hill Group

Desired Coverage Option *

If you select "Custom Coverage," please provide a detailed description of your desired coverage options in the box below.

Gold Coverage - base coverage including terrorism and including nuclear, biological, chemical materials - no terrorism exclusion shall apply. No nuclear/biological/chemical exclusion shall apply up to the lessor of the full policy limit or $10,000,000 per event.

Silver Coverage - base coverage, including terrorism but excluding nuclear, biological, chemical materials. No terrorism exclusion shall apply. Acts and threats of terrorism that involve nuclear/biological/chemical materials are excluded.

Bronze Coverage - base coverage, excluding terrorism coverage

Please provide quotes for all 3 options (Gold, Silver & Bronze)

Custom Coverage

Primary Contact Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

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 Event Location *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

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

Is there an ability to reschedule? *

Yes

No

Will the event be *

Indoors

Outdoors

Under Temporary Structures

Indoors with some outdoor elements

Type of Event *

Marathon

Half Marathon

10K

8K/5 Mile

5K

1 mile

Triathlon

Non-traditional/Obstacle Race

Other (please provide full details below)

Do you want to insure Gross Revenue or Expenses? *

Select One

Gross Revenue

Expenses

Do these sums represent the full extend of your financial responsibilities? *

If No, please 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

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

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. You acknowledge that you are submitting an application for insurance, and that your typed name below constitutes your signature, acceptance and agreement as if actually signed by you in writing. You further acknowledge and agree that the taking of any such actions by you evidence your intent to sign any such agreement, acknowledgment, consent, terms, disclosures or conditions. You also agree that no certification authority or other third party verification is necessary to the validity of your electronic signature; and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature or any resulting contract. 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