A Service of Supple-Merrill & Driscoll, Inc.




 Single Special Event Application Instructions

  1. Please complete and submit this online application for a free, no-obligation quote.

  2. Please be sure to provide all required information in order to receive a quotation.

  3. Event Cancellation coverage cannot be quoted less than 15 days prior to the event.


  Program Information

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  PDF Application (Fillable)


( indicates required information)

Applicant Information

Name of Company / Organization:

Full Name of Contact:
Street Address:
City, State: ,
Zip/Postal Code:


We will never rent, sell, or share your email address.

Applicant Type:


Qualification Questions

Does the event include any of the following?

Stunts, Pyrotechnics, Aircraft, Hazardous Activities, Car Races, Precision Driving, Mechanical Amusement Devices, Film Production, Live Rap or Hip-Hop Performances

The event will take place in the United State or Canada?

Confirm on one event can be covered per policy:
Any bounce houses or inflatables?

If yes, certificates of insurance from vendor are required.

Any private armed security?

(i.e. armed security that work exclusively for you under your employ)


Insurance History

Any insurance declined or cancelled in the past 3 years?

Any loss in the past 3 years?

Not applicable in MO

If Yes, please describe.

Any prior insurance coverage?


Event Details

Event Category:
Event Name:
Event Description:

Event Cost/Budget:

How much the event is costing to put on.

If a Music Festival, How Many Bands:

Artist(s) / Band(s):

Required if live music or a concert event.

Music Category (If any):

Hold Ctrl to select multiple categories.


There will be celebrities at the event.
There will not be celebrities at the event.



Setup Date(s): to (if any)

The period before the event to arrange.

Attendees will not be present during the setup.

Select up to 7 days at no additional premium.

Event Date(s): to (required)

The duration the actual event will take place (not including setup and teardown).

Attendees will be present during the actual event.

Tear Down Date(s): to (if any)

The period to dismantle after the event.

Attendees will not be present during tear down.

Select up to 7 days at no additional premium.

Event Hours:  to
Total Number of Days:


Venue Details

Location Where Event Takes Place - Only One Venue Per Policy

Venue Name:
Event Location:

Medical or EMS Available:

Athletic Events

Private Armed Security Guards:

Private Armed Security Guards make the event ineligible for our program.


Vendor's Liability

Option to Extend Coverage to Vendors

The policyholder is 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 (no sales):
# of Concessionaires (non-food sales):
# of Concessionaires (food sales):
# of Attractions (performers):


Average Daily Spectators:
Average Daily Participants:

Sporting / Theatrical Participants


Inland Marine

Equipment & Property Coverage

Equipment, Props, Sets, Wardrobe (Rented):
Equipment, Props, Sets, Wardrobe (Owned):

Rented Furs, Jewelry, Art & Antiques Coverage:

The Props, Sets & Wardrobe form provides up to $25,000 for furs, jewelry, arts, antiques coverage.  If a higher limit is required, include the additional limit under this coverage.  A schedule/appraisal for the item(s) will be required.

Extra Expense:
Third Party Property Damage:

Hired & Non-owned Auto Physical Damage:

Per Vehicle / Aggregate Limit

Rental Cost Reimbursement:

Covers the potential additional expense to rent similar equipment after a loss.

Waiver of Subrogation:

Coverage Extension Endorsement:

Valuable Papers


Signs 10,000
Outdoor Property 5,000 Per Item
25,000 Total
Electronic Media And Records 5,000
Debris Removal 50,000
Employee Dishonesty 5,000
Fire Department Service Charges 25,000
Fire Equipment Recharge 10,000
Pollutant Clean Up And Removal 15,000
Sewer Backup 25,000
Temporary Location 25,000
Accounts Receivable 25,000
Money & Securities 5,000


General Liability 
Occurrence/Aggregate Limit:
Fire Legal:
Medical Payments:

Blanket Additional Insureds / Certificates of Insurance:


Blanket Additional Insureds allow for unlimited certificates to vendors and locations.  City certificates, other special certificates, and Waivers of Subrogation are picked-up under their respective coverages.

City / Other Special Certificates:

FilmL.A., Inc., NYC Mayor's Office of Film, Cities that require Special Wording on Certificates, etc.

Waiver of Subrogation:

Primary & Non-Contributory Wording Only if Required by Locations and Vendors.

Employee Benefits Liability:

Liquor Liability:

Host Liquor Only provides coverage under the General Liability form if the insured is not in the business of manufacturing, selling, serving, or furnishing alcoholic beverages. Full Liquor Coverage provides coverage under a separate liquor liability form. Full Liquor Coverage is not available in the following states NC, RI, VT.

Liquor Sales:
Percentage of Attendees Estimated to Consume Alcohol:
Abuse & Molestation:

Each Claim / Aggregate


Hired / Non-Owned Liability:
Waiver of Subrogation:

Hired & Non-Owned Auto Liability is rated based upon the cost to rent vehicles, duration of rentals and the number of vehicles that will be rented.

Number of Loaned or Donated Vehicles / Days:

# of Days

# of Vehicles

Cost of Hire:

Mobile Studios and Film Trucks

Other Than Mobile Studios and Film Trucks


Excess Liability

Occurrence / Aggregate Limit:

The Excess Liability is an additional layer of coverage above the General Liability, Auto and Employer's Liability.  Not that this Excess policy will only sit on top of risks insured through this program.


Workers' Compensation

Available in: AL, AR, AZ, CA, CO, CT, DC, FL, GA, IA, ID, IL, IN, KS, KY, LA, MD, ME, MI, MO, MN, MS, MT, NC, NE, NH, NJ, NM, NV, NY, OK, PA, TN, SC, TX, UT, VA, VT, WV.

In addition, for clients located in the above states, locations can now be added for operations that occur in the following 8 states: AK, DE, HI, MA, OR, RI, SD, WI.


Waiver of Subrogation:

Primary & Non-Contributory Wording

All States Endorsement (other than monopolistic states):

Payroll Company:

If Any

Identification Number:

An identification number  is required when binding Workers' Compensation coverage.

Payroll by Class Codes (if any)

# Full Time Employees

Over 25 hours/week

# Part Time Employees

Under 25 hours/week


Total W-2, 1099, & Deferred

8742 - Salespersons - Outside:
8810 - Clerical Office Persons - NOC:
9154 - Crew:
9156 - Performers & Musicians:


Full Name


Schedule an Officer:

Workers compensation coverage is not provided for officers & owners. The title for at least one officer/owner must be entered in order to proceed. To capture the required information, edit and select the title for any existing contact, and/or enter a new officer/owner.


Please provide complete street address for a location each state.

Although the workers compensation policy includes an all states endorsement, certain states may deny benefits if an address in that state is not scheduled on the policy.

To minimize the chance of a claim denial, please schedule a location in each state that the production will occur.  Only one location in each state is required.

Note: All productions shooting in New York are required by the NY Workers Comp Bureau to schedule a NY Location.


Spectators & Participants Medical

Available in all states except MD, MO, OH & WA

Accident Medical Benefit:

Death / Dismemberment / Medical

Covered Individuals:







Terms and Conditions

Please carefully review the Terms and Conditions below:

  • Please read all exclusions indicated on quotation.

  • The quotation received is not binding on the Insurer in any way.

  • By clicking 'Submit Application' you are not agreeing to purchase coverage.  Via email, you will receive a free, no-obligation insurance quotation.

  • Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and (NY: substantial) civil penalties. (Not applicable in CO, HI, NE, OH, OK, OR, VT). In DC, LA, ME, TN and VA, insurance benefits may also be denied.
  • Please note that once coverage is bound, the policy cannot be cancelled.

  • The insurance quotation will be based solely on the coverages and limits selected on this application.

  • Please ask your Supple-Merrill & Driscoll, Inc. representative to explain coverage details, exclusions, limits or other provisions of any insurance policy.

Type your name below, to indicate that you have read

and accepted the Terms and Conditions above:





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