LIO Special Events Application

1. Producer & Submission Info

Brokerage / Agency

Producer / Broker Name

Producer Email

Producer Phone

Desired Effective Date *

Expiration Date

Tax Status *

For-Profit Tax Exempt

ⓘ Effective date must fall within 365 days from the date of submission. Coverage effective dates cannot precede the date the completed application is received.

2. Named Insured

Named Insured (Legal Name) *

DBA / Trade Name

Business Type *

Primary Contact

Phone

Email Address *

Website

Mailing Address

Street Address *

Street Address 2

City *

State *

Zip Code *

3. Event Venue

Enter the primary venue or location where the event will be held. If same as mailing address, check below.

Same as mailing address

Venue / Location Name *

Street Address

City *

State *

Zip Code

4. Coverage Requested

Lines of Coverage

General Liability (required) Sexual Abuse & Molestation (SA&M) Liability Excess Liability Inland Marine (event equipment, staging, rented property) Hired & Non-Owned Auto Liability

General Liability Limits

Occurrence / Aggregate Limit *

$1M / $3M $2M / $4M

Certified Acts of Terrorism (TRIA) *

Accept TRIA Coverage Reject TRIA Coverage

Optional Coverage Limits

SA&M Limit Option

Excess Liability Limit

Inland Marine Total Limit

Standard GL Inclusions

Products / Completed Ops • Personal & Adv. Injury $1M • Damage to Premises $100K • Med Pay $5K

5. Event Details

Event Classification

Event Category *

Sporting Event Non-Sporting Event

Event Basis *

ⓘ Sporting events are rated per participant per day. Non-sporting events are rated per spectator / attendee per day. Activity risk classification (Low / Medium / High) determines rate within filed range.

Event Schedule & Activity Detail

ⓘ Complete one row per event or activity. List activity type (e.g., Soccer Tournament, Wedding Reception, Concert), event dates, duration, and expected counts.

#	Activity / Event Type	Start Date	# of Days	# Participants	# Spectators	Risk Class (L / M / H)
1
2
3
4
5
6

ⓘ Events with more than 5,000 spectators will trigger a referral for underwriter review.

Event Description & Purpose

6. Operations Profile

Applicant Role

Is the applicant the event organizer, host, or promoter?

Yes No

Coverage under this program requires the applicant to be the event organizer, host, or promoter. Third-party participants or attendees only are not eligible.

Event History

Has this event been held in the past?

Yes – recurring or previously held No – first-time event

Venue & Setup

Is the venue properly licensed and permitted for this event?

Yes No

Will the event's expected attendance remain within the venue's certificate of occupancy?

Yes No

Is a written venue use agreement in place?

Yes No N/A

Is the event held outdoors, indoors, or both?

Indoor Outdoor Both

Alcohol Service

Will alcohol be served, sold, or available at the event?

Yes No

Ancillary Operations

Will the event include concessions or food vendors?

Yes No

Will security personnel be on site during the event?

Yes No

Will minors (under 18) be participating or attending?

Yes No

Will any overnight accommodations be provided as part of the event?

Yes No

Is an Additional Insured endorsement required?

Yes No

Additional Insured Name & Description (if yes, please complete the below)

7. Underwriting Supplemental

Prior Insurance

Current / Prior Carrier

Prior Policy Expiration Date

Prior Annual / Event Premium

A. General

Has the applicant had insurance denied, cancelled, or non-renewed by an insurer in the last 5 years for a coverage being requested?

Yes No

Has the applicant been involved in any bankruptcy, criminal, or civil proceedings?

Yes No

Has the applicant experienced a loss in the last five (5) years for a coverage being requested?

Yes No

B. Waivers & Participant Releases N/A

Applicable when the event includes athletic, recreational, or active participation by attendees.

Does the organization require all participants to sign a waiver or release before participating?

Yes No

Do waivers specifically address the inherent risks of the activity?

Yes No

For youth participants (minors), are waivers signed by a parent or legal guardian?

Yes No N/A

C. Sexual Abuse & Molestation (SA&M) Controls N/A

D. Crowd & Safety Standards N/A

Will the organizer conduct a venue safety walk-through prior to the event?

Yes No

Will first aid supplies and trained personnel be available on site?

Yes No

Is an emergency action plan (evacuation, severe weather, medical) documented and shared with staff?

Yes No

Do all third-party vendors (caterers, entertainers, equipment providers) carry their own liability insurance?

Yes No N/A – None used

E. Ineligible Exposures Declaration

The applicant must review the following ineligible operations and exposures. By checking the box below, the applicant confirms that none of these apply to the event.

Ineligible Operations & Exposures

Pyrotechnics or open-flame performances
Motorsports, ATV, or motorized vehicle races / exhibitions
Aerial acts, hot-air balloons, bungee jumping, zip-lines
Events at unlicensed or unpermitted venues
Political rallies or protest events
BYO or self-serve alcohol arrangements
Haunted houses, escape rooms, immersive horror experiences
Demolition derbies, tractor pulls, stunt events
Events exceeding venue certificate of occupancy
Extreme / adventure races (Tough Mudder, Spartan, Ironman)
Professional / semi-professional sporting events
Boxing, MMA, or combat sports events
Large stadium / arena events (>5,000 spectators)
Skydiving, parasailing, hot-air balloon events
Carnivals or circuses with mechanical rides
Events with bull riding, rodeo, or equestrian competition

I confirm that the applicant does not participate in, host, or have any involvement with any of the ineligible operations or exposures listed above.

8. Additional Named Insured

Complete if any additional entities (co-hosts, sponsors, venue owners) require named insured status. Attach a schedule if more than one.

Name

Description / Relationship

Ownership / Affiliation %

Address

9. Supporting Documents

Please send the following along with this completed application back to your underwriter. Loss runs are required for recurring events — everything else is greatly appreciated if available at this time. The more we have upfront, the smoother the process!

Required (Recurring Events)

4-year loss runs dated within 3 months of the proposed effective date (recurring events only)

Also Appreciated — Please Include Any of the Following if Available

Event itinerary, schedule, or run-of-show
Sample participant waiver / release form
Venue contract / use agreement
Vendor / contractor list with proof of insurance
Background check policy (if SA&M coverage is requested)
Emergency action plan / safety plan
Marketing materials, website, or event flyer
ACORD 126 / GL supplement

Additional Notes for Underwriter

10. Fraud Warning & Declaration

⚠ NOTICE TO POLICYHOLDERS — FRAUD NOTICE (NTC FR01 10/21)

NOTICE TO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent act, which is a crime, and may subject such person to criminal and civil penalties.

NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof.

NOTICE TO ARKANSAS, LOUISIANA, RHODE ISLAND, AND WEST VIRGINIA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO CALIFORNIA APPLICANTS: For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

NOTICE TO KANSAS APPLICANTS: Any person who knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance that such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.

NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other 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.

NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

FIRE: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

NOTICE TO OKLAHOMA APPLICANTS: Warning: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

NOTICE TO OREGON APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, may be guilty of a fraudulent act, which may be a crime, and may subject such person to criminal and civil penalties.

NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 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 such person to criminal and civil penalties.

NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

NOTICE TO VERMONT APPLICANTS: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

I DECLARE THAT THE STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND TRUE. The undersigned authorized representative affirms that all information provided is accurate and complete to the best of their knowledge. The applicant certifies that no material facts have been concealed or misrepresented, no claims or circumstances that could give rise to a claim are known and undisclosed, and all described operations are within the scope of eligible events under the LIO Special Events program. Misrepresentation of material facts may result in rescission of coverage from inception. Coverage is not bound until confirmed in writing by LIO Insurance.

11. Signatures

Applicant / Authorized Representative

Applicant / Authorized Representative Name

Title

Applicant Signature

Signature

Date

Producer / Broker

Producer Name

License Number

Producer Signature

Signature

Date