Prizetech - Cancellation Insurance Proposal Form

Name of Proposer(s) *

Phone Number *

Email Address *

Address *

Street address *

City *

State *

Postcode *

What is your usual business(s)? *

How long have you been in this business? *

What is your role? *

Event OrganiserOther

Please specify what your role is *

Title or name of Insured Event *

Type of event to be insured *

Please provide a brief description of the Insured Event *

Time of Insured Event *

Date of Insured Event *

What date does set-up begin? *

What time does set-up begin? *

Name of Venue *

Venue Address *

Street address *

City *

State *

Postcode *

How long could the start of the Insured Event be delayed? (Please provide full details) *

Event Website *

Has the Insured Event been held before? *

YesNo

Please provide full details *

Is the Insured Event part of a larger production, promotion, series or tour? *

YesNo

Please provide full details *

Is rescheduling / postponement possible for the Insured event? *

YesNo

Please explain why *

Will the Insured Event be held wholly or partly in the open air, in a marquee or in a temporary structure? *

YesNo

Please specify what proportion will be held in the open air, marquee / tent, or other temporary structure *

Would the Proposer(s) like Underwriters to consider offering terms to include the effect of adverse weather? *

YesNo

Please complete the Outdoor Event Appendix A Form here.

Will the non-appearance of any Person cause Cancellation, Abandonment, Postponement, Interruption, Curtailment or Relocation of the Insured Event? *

YesNo

Would the Proposer(s) like Underwriters to consider offering terms for the Non Appearance of those persons? *

YesNo

Please complete the Outdoor Event Appendix B Form here.

Will the Proposer(s) have a signed written contract for the lease or hire of venue(s) prior to inception of this Insurance *

YesNo

Please provide a full explanation *

Have all other contractual arrangements necessary for the fulfilment of the Insured Event(s) been made and confirmed in writing? *

YesNo

Please provide a full explanation *

Does the Proposer(s) undertake to make all such remaining contractual arrangements in a prudent and timely manner and ensure they are confirmed in writing prior to the relevant Insured Event? *

YesNo

Please provide a full explanation *

Have all necessary licences, visas, permits and authorisations been obtained? *

YesNo

Please provide a full explanation *

Please provide budgeted expense details below (Please show currency): *

General Administration

Printing, Promotions and Advertising

Venue Hire

Facilities and equipment rental

Communication Costs

Sponsorship

Wages, Salaries and Benefits

Broadcasting and TV Rights

Insurance other than Insured Hereon

Other (please provide details)

Total Expenses

Please provide budgeted revenue details below (Please show currency): *

Gate / Ticket Sales

Programme Sales

Merchandising

Fees

Commissions

Sponsorship

Advertising

Concessions

Broadcasting and TV Rights

Other not included above (please provide details)

Total Gross Revenue

For information purposes only, the amount by which Budgeted Gross Revenue exceeds Budgeted Expenses will represent the Proposer's Budgeted Net Profit.

The Proposer(s) may elect to insure either the Total Expenses or the Total Gross Revenue.

Please indicate your preference below: *

Total ExpensesTotal Gross RevenueOther

If you wish Underwriters to consider insuring a different Limit of Indemnity, please tick other.

Please provide details *

Does any other party have an interest in the Gross Revenue? *

YesNo

Please provide details *

What proportion (%) of tickets are sold / revenue generated in advance of the Insured Event? *

Do you have a ticket refund policy in place? *

YesNo

Please provide details of the refund policy *

What system do you have in place? *

Has any event in which the Proposer(s) was/were involved (in managing) had any incident that resulted in Cancellation, Abandonment, Postponement, Interruption, Curtailment or Relocation of the Insured Event? *

YesNo

Please provide details *

Has the Insured Event (under the present or any other management) had any incident that resulted in Cancellation, Abandonment, Postponement, Interruption, Curtailment or Relocation of the Insured Event? *

YesNo

Please provide details

Are you aware of any matter, fact, circumstance or incident existing or threatened that might reasonably result in Cancellation, Abandonment, Postponement, Interruption, Curtailment or Relocation of the Insured Event? *

YesNo

Please provide details

Loss Payee (if other than Proposer(s) stated in Question 1) *

Declaration

To the best of my/our knowledge and belief and having diligently made all necessary inquiries the information provided in connection with this proposal, whether in my/our own hand or not, is true and I/we have not withheld any material facts. I/We understand that non-disclosure or misrepresentation of a *material fact will entitle Underwriters to void the Insurance.

NOTE: A material fact is one likely to influence acceptance or assessment of this Proposal by Underwriters: if you are in any doubt as to what constitutes a material fact you should consult your Broker.

It is understood that the signing of this Proposal does not bind the Proposer(s) to complete or Underwriters to accept this Insurance, but the Proposer(s) agree that, should a contract of insurance be concluded, this Proposal 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 may become null and void if any of the foregoing conditions are breached.

Name *

Date *

Position *

Signature

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