Folk Alliance Event & Festival Application

General Information

Named Insured: *

(the legal name of the organization or business; typically the name that appears on contracts & agreements)

Doing Business as (DBA): *

(additional name(s) under which the named insured may operate)

Mailing Address *

City, State & Zip Code *

Contact Full Name *

Contact Phone Number *

Email: *

FAI Member Number *

(if member number is pending please state "pending")

FAI Membership Expiration Date:

Event Website: *

Business Information

1. Are Overnight Camping Accommodations part of the Event? *

If so, are you responsible for the camping area?

2. Will the event feature any of the following activities:
Rides, Amusement Devices, Inflatable Recreational Devices?
Petting Zoos or Animals?
Fireworks or Pyrotechnics?

The exposures/activities listed above are not covered by this program and any resulting claims will be denied. If you wish to cover any of these activities, please contact us to determine if other coverage options are available. If any of these activities are provided by a third party you should require evidence of liability coverage (certificate of insurance) from the entity/organization naming you as an additional insured.

3. Does the event have concessionaires, exhibitiors or any vendors? *

4a. Alcoholic Beverages (please pick the choice that best describes your event)

4b. If alcohol is sold or furnished at the event who holds the liquor license? *

Event Details

Name of Event: *

Description / Type of Event: *

Venue Name *

Venue Address *

Venue City, State & Zip Code *

Set-Up Start Date:

Tear-Down End Date:

Event Start Date: *

Event End Date: *

Daily Hours of Event

Premium Calculation

A. Average Daily Attendance: *

B. Number of Event Days *

C. Total Attendance (A x B): *

Choose Program Premium Category (using the answer to "C" above)

*

0 - 350 attendees (one day) = $115
0 - 500 attendees = $160
501 - 1,500 attendees = $280
1,501 - 3,000 attendees = $490
3,001 - 6,000 attendees = $910
6,001 - 12,000 attendees = $1,570
12,001 - 20,000 attendees = $2,610

Choose Overnight Camping Charge:
*

No Camping = $0
Camping = $285

Total Premium Due (Program Premium plus Camping Charge) *

Florida 1.3% Surcharge (Florida Applicants need to add a 1.3% mandated Hurricane Catastrophe Fund assessment Fee to the total premium)

Certificate of Insurance Request

Type of Certificate Needed:
(you will automatically receive a proof of coverage, this section is for others who need to see proof of coverage?)

Additional Insured
Evidence of Coverage

Certificate Holder Name

Mailing Address

City, State & Zip Code

Contact Name:

Contact Email Address:

Contact Phone Number:

Warranty Statement

I understand that the insurance company, in determining whether to provide insurance coverage, will rely on the information contained in this form and all other information being submitted. I hereby warrant, represent and confirm that, to the best of my knowledge, all information provided is complete, true and accurate.

I am aware that the insurance company expects accurate reporting for my premium calculation. I understand that my books and records may be examined or audited by the insurance company at any time during the coverage period and up to three years thereafter. Intentional misrepresentation or misreporting may jeopardize coverage.

I further acknowledge that I have reviewed all information provided with this enrollment form and understand the exclusions that apply, as well as the activities and operations for which coverage is not provided. *

I accept

Signed By (enter full name of authorized representative) *

Relationship to Insured *

Folk Alliance International Event Insurance Application

Follow Me