1) The Insureda) Full name of proposed Insured including subsidiaries:Company Name*ABN*b) Contact DetailsContact Name* First Last Contact number*Email* Contact Mobile number*Postal Address* Street Address Address Line 2 City State Postcode c) Venue AddressAddress* Street Address Address Line 2 City State Postcode Start Date DD slash MM slash YYYY Finish Date DD slash MM slash YYYY 2) TurnoverEstimate annual turnover for the forthcoming period*Estimate wages for the forthcoming period*Details of Employee Activities*Do you use Volunteers?* Yes No If so, provide details of Volunteer Activities belowDo you engage Subcontractors?* Yes No If so, please providei) Estimated Subcontractor payments for the forthcoming periodii) Details of Subcontractor activities belowDo you ensure that all performers, subcontractors, contractors and all other service providers provideproof of their own Public Liability Insurance?* Yes No documented evidence such as a certificate of currency?* Yes No Do you use Labour Hire?* Yes No If so, please providei) Estimated Labour Hire payments for the forthcoming periodii) Details of Labour Hire activities belowWill there be any use of fireworks / pyrotechnics?* Yes No 3) Description of the VenuePlease provide full details of what your business entails*Number of Entertainers / Musicians / Performers*4) Type of PerformancesWill there be any audience participation* Yes No If yes, please provide details below5) Sound / Lighting LiabilityDo you hire equipment in?* Yes No If yes, please describe belowMaximum Value of hired equipment*6) Specific Event LiabilityLicensed capacity of the venue*Have you signed a venue contract?* Yes No If yes, please provide a copyMax. file size: 8 MB.What is your role in the venue* Promotor Principal Event Organiser Event Coordinator Production Manager Other What is the estimate attendance?Will alcohol be sold / supplied?* Yes No Are you responsible for the sale / supply of food and drink?* Yes No Do you hold the appropriate license for such activities?* Yes No Will a stage/s be used at any time during the event?* Yes No Please provide dimensionsHeightWidthLengthIs the stage a temporary structure?* Yes No Who will provide and set up the stage/sHave you staged similar events in the past?* Yes No 7) Risk ManagementAre you aware of all industry rules, regulations and standards applicable to your business activities?* Yes No Are you complaint with existing industry rules, regulations and standards applicable to your business activities?* Yes No 8) Claims and/or Loss ExperienceHave you had any insured and/or uninsured claims in the last five years?* Yes No If yes, please provide details belowDatesClaims ReportedAmount paid & OutstandingApplicable DeductibleDescription of loss/claimInsurer After investigation, is the Proposer aware of any circumstances which could rise to a claim under a previous policy?* Yes No If yes, please provide detailsHas any insurer ever refused to provide terms or offer renewal terms to the Proposer or has any insurance held by the Proposer ever been violated or cancelled by an insurer?* Yes No Has the Proposer ever had any entitlements to indemnity under any Insurance Policy declined or, otherwise affected due to non-disclosure misrepresentation or breach of a policy provision?* Yes No If yes, please provideAmount of Indemnity Required* $10 million $20 million DeclarationI declare that to the best of my knowledge and belief the answers given above or documents submitted the true position and that I have not withheld any material information from this proposal. I agree that this proposal and any accompanying shall form or partly form the basis of the Contract Proposed.Signature*Date* DD slash MM slash YYYY Name*Title/Position*CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
