SPECIAL EVENTS LIABILITY COVERAGE OUTLINE FOR MISSOURI UNITED SCHOOL INSURANCE COUNCIL
COVERAGES: $1,000,000 $ N/A $1,000,000 $1,000,000 $ 50,000 GENERAL AGGREGATE PRODUCTS/COMPLETED OPERATIONS AGGREGATE PERSONAL INJURY/ADVERTISING INJURY EACH OCCURRENCE FIRE DAMAGE
$250 LIABILITY DEDUCTIBLE BODILY INJURY/PROPERTY DAMAGE PER CLAIM, INCLUDING LOSS ADJUSTMENT EXPENSE AND DEFENSE. KEY EXCLUSIONS: (See policy for a complete list) TERRORISM NUCLEAR ENERGY PUNITIVE DAMAGE ASBESTOS ABSOLUTE POLLUTION MEDICAL PAYMENTS LEAD CONTAMINATION ASSAULT & BATTERY PARTICIPANTS AND PERFORMERS RATES: (PER DAY*/PER EVENT BASIS) UNDER 1000 ATTENDEES = $68.00 OVER 1000 ATTENDEES = $95.00 $100 FOR EACH ADDITIONAL INSURED PLUS $5 SURPLUS LINES TAX THESE RATES ARE GOOD THROUGH 12/31/05 *PER DAY MEANS A START TIME BETWEEN 12:01 AM AND MIDNIGHT. IF AN EVENT CONTINUES PAST MIDNIGHT IT IS CONSIDERED A TWO-DAY EVENT AND TWO DAYS PREMIUM WILL BE CHARGED.
C:\staging\4210D0DC-64A8-18EB12\in\4210D0DC-64A8-18EB12.doc
Revision Date: 02/14/05
SAMPLE COMPLETED APPLICATION FORM
M.U.S.I.C. SPECIAL EVENTS COVERAGE
NAME, ADDRESS & PHONE NUMBER OF PERSON(S), GROUPS/ORGANIZATIONS RENTING/USING YOUR FACILITIES. NAME OF ORGANIZATION/GROUP: Ladies Auxiliary Club NAME OF CONTACT: CONTACT ADDRESS: 103 1st St., Ourtown, MO CONTACT PHONE NUMBER: (660) 201-5678 TYPE OF EVENT: Bingo
DATE OF EVENT: 7/4/05 *NUMBER OF ATTENDEES: 300
($68.00 RATE APPLIES TO UNDER 1,000 ATTENDEES) ($95.00 RATE APPLIES TO OVER 1,000 ATTENDEES) ($1,000,000 LIABILITY LIMIT) ($100 PLUS $5 TAX FOR EACH ADDITIONAL INSURED) THE ABOVE RATES ARE GOOD THROUGH 12/31/05. IF YOUR EVENT TAKES PLACE AFTER 12/31/05 PLEASE CALL FOR CURRENT RATES.
MUSIC MEMBER: ABC R-II ADDRESS: 123 America Way, Ourtown, MO
PHONE NUMBER: (660) 201-1234 COMPLETED BY:
*$68.00 OR $95.00 FEE APPLIES ON A PER DAY BASIS A CHECK MUST ACCOMPANY THIS FORM; ENVELOPE WITH CHECK MUST BE POSTMARKED PRIOR TO THE EVENT. PER DAY MEANS START TIME BETWEEN 12:01 A.M. AND MIDNIGHT. IF AN EVENT CONTINUES PAST MIDNIGHT, IT IS CONSIDERED A TWO-DAY EVENT AND TWO DAYS PREMIUM WILL BE CHARGED. CHECK SHOULD BE MADE PAYABLE TO: M.U.S.I.C. PLEASE FORWARD THIS FORM AND CHECK TO: ARTHUR J. GALLAGHER & CO. ATTN: ADA HEQUEMBOURG 12444 POWERSCOURT DRIVE ST. LOUIS, MO 63131 IF YOU HAVE ANY QUESTIONS REGARDING THIS COVERAGE, PLEASE FEEL FREE TO CONTACT ADA HEQUEMBOURG AT (800) 877-8218 OR (314) 965-4346, EXT. 397.
APPLICATION
M.U.S.I.C. SPECIAL EVENTS COVERAGE
NAME, ADDRESS & PHONE NUMBER OF PERSON(S), GROUPS/ORGANIZATIONS RENTING/USING YOUR FACILITIES. NAME OF ORGANIZATION/GROUP: NAME OF CONTACT: CONTACT ADDRESS: CONTACT PHONE NUMBER: TYPE OF EVENT: DATE OF EVENT: *NUMBER OF ATTENDEES:
($68.00 RATE APPLIES TO UNDER 1,000 ATTENDEES) ($95.00 RATE APPLIES TO OVER 1,000 ATTENDEES) ($1,000,000 LIABILITY LIMIT) ($100 PLUS $5 TAX FOR EACH ADDITIONAL INSURED) THE ABOVE RATES ARE GOOD THROUGH 12/31/05. IF YOUR EVENT TAKES PLACE AFTER 12/31/05 PLEASE CALL FOR CURRENT RATES.
MUSIC MEMBER: ADDRESS: PHONE NUMBER: COMPLETED BY:
*$68.00 OR $95.00 FEE APPLIES ON A PER DAY BASIS A CHECK MUST ACCOMPANY THIS FORM; ENVELOPE WITH CHECK MUST BE POSTMARKED PRIOR TO THE EVENT. PER DAY MEANS START TIME BETWEEN 12:01 A.M. AND MIDNIGHT. IF AN EVENT CONTINUES PAST MIDNIGHT, IT IS CONSIDERED A TWO-DAY EVENT AND TWO DAYS PREMIUM WILL BE CHARGED. CHECK SHOULD BE MADE PAYABLE TO: M.U.S.I.C. PLEASE FORWARD THIS FORM AND CHECK TO: ARTHUR J. GALLAGHER & CO. ATTN: ADA HEQUEMBOURG 12444 POWERSCOURT DRIVE ST. LOUIS, MO 63131 IF YOU HAVE ANY QUESTIONS REGARDING THIS COVERAGE, PLEASE FEEL FREE TO CONTACT ADA HEQUEMBOURG AT (800) 877-8218 OR (314) 965-4346, EXT. 397.