Liability for Performers/ Entertainers Including Miscellaneous Property DIRECT CLIENT SUBMISSION

2 Norfolk St. South Simcoe, ON, N3Y 2V9 T: 1-800-265-8098 F: 519-428-5661 E: [email protected] www.palcanada.com

Fax or e-mail of this application must be received by our office a minimum of one day prior to the Effective Date. The Transmission Confirmation Report from your fax machine or sent email is proof you have submitted the application to PAL Insurance.

This application IS NOT INTENDED for performers/ entertainers who are organizing/ hosting an event. The event host MUST carry a separate event liability policy. EXCLUDES all performances at Nightclubs.

Name of Insured (s):

If an individual, date of birth:

Mailing Address:

City, Province: Postal Code:

Telephone: ( ) Website:

Effective Date: (MM/DD/YY) Effective Time: AM PM Expiry Date: (MM/DD/YY) Expiry Time: AM PM Event Location: (if coverage for 1 event only is required) Address:

Estimated Attendees/ performance: Estimated # of Performances/ year: Annual Receipts: $ How many members in Group/band:

Limit of Liability: $1,000,000.00 $2,000,000.00 $3,000,000.00 $4,000,000.00 $5,000,000.00

Please select the most appropriate Category ( Check Category & Circle Performer ): Category I - AS PER RATING MATRIX Composers Jazz, Folk or Classical Band Photo Booth Actors Computer Art Karaoke Photographer / Photography Storytelling After Dinner Speakers Concept Visualization Kissogram Poet Strongmen Art and Craft Skills Corporate Entertainment Kite Preacher Table Top Games (Non-Alcohol) Art Consultancy Costume Characters Lasso Public Speaking Tap Dance Teacher Artists Dance Troupe Lecturers Puppeteers Textile Artists Arts Lecturers Dancer Lookalikes Quizmasters Theatrical Props Athlete or Athletic Performers Disc Jockeys (NOT in nightclub) Master of Ceremonies / MC's Rangoli Theatrical Stage Group Authors Dough Modeling Maypole Dancing Researchers Toastmasters Balloon Artist Drama Club Meet and Greet (book Resident Entertainer Tour Guides Basket Weavers Drawing signing/autographs) Ribbon Twirling Town Crier Belly Dancer Flower Arrangements Mime Artists Ringmaster Ventriloquist Cameos Gymnastics Museum Educator Role Player Videographer Caricaturist Hair Braiding Music Teachers Sculptors Viking Characters Cartoonist Hair Extensions Musician (individual) Silhouette Artist Vocalists Celebrity Look-Alike Hair Painting Nail Art Singing teacher Voice Coach Character Shows Hair Wrapping Organist Singers Walkabouts Cheerleading Hairdressers Origami Songwriter Writer Chocolate Fountain Hula Hooping Painter (not construction) Speech Teacher Yo-Yo Choirs Comedians Human Statues Pantomimes Stage Performer Community Artist Impersonator / Impressionist Performance artist Stand Up Comedy Inc. Props

Category I I - SUBMIT FOR QUOTE Category III - SUBMIT FOR QUOTE Animal Act Performers (Excluding dangerous animals) Acrobats Circus Performers Excluding Makeup Artists Airbrush fire, knife, Martial Arts display Escapologist Fakir Astro Jacks Clown Mural Work Balancing Acts Contortionist Physical Theatre Fortune Tellers Glass Walking Bed of Glass Cosmetic Make-up Plate & Ball Spinning Bed of Nails Cycling Acts (Trick Cyclists / Poi Sticks Historical Enactments Mediums Bicycle Unicyclists) Re-Enactment Artist Board Breaking Devil Sticks Rola Bola Mobile Casino Palm Reading Body Art Face / Body Painter Skateboard Tricks Body Brush Art Globe Walking Tattoos - Airbrush Rap or Hip Hop Burlesque Acts & Striptease Henna Artist Tattoos - Glitter Rock or Pop Band Busker Holiday Characters Tattoos- Henna Tarot Card Reader Cabaret Act (Santa/Elf) Tattoos- Temporary Carnival Performers Juggler Wedding Decorator Childrens Entertainers Limbo Dancing Whip Cracker Choreographer Low Wire Acts Performer Liability and Miscellaneous Property Application ~ Client Submission For the purposes of the Insurance Companies Act (Canada), this document was issued in the course of Lloyd’s Underwriters’ insurance business in Canada. Category I V - SUBMIT FOR QUOTE *Supplementary Questionnaire may be required Aerial Performers * Angle Grinding Performers Bubble & Smoke Machines Fire Acts Eaters Breathers * Illusionist * Spiritual Healing * (outdoor only) Carving (knife, chain saw, (outdoor only) Inflatables Sword Dance Unarmed Combat Display wood, ice, etc) Fire Acts Jugglers (outdoor Magician * Sword Fighting Arrow Breaking Chain and Pole Swinging only) * Mind Reading * Sword Swallower Blacksmith Demonstration Chinese Pole (aerial ) Glass blower Mini Bike Tight Rope Artist * (outdoor only) Clown Car High Wire Acts * Sleigh/Wagon Rides Trapeze Artists * Fire Acts (outdoor only) * Hypnotist * Snake Charmers List the type of performer selected above:

PAL’s Performer program automatically includes up to $25 000.00 of property coverage, please provide the following details:

Miscellaneous items to be insured (include serial number, security etching, or make if possible) : Qty: Total Value:

Are the items: Owned Rented (Rental Contract must be attached to this application)

When the property is not in used at an event, where is it stored?

Address:

City, Province: Postal Code:

While the property is not in use, it must be stored at a location that is secured AT ALL TIMES with at least one A- locked doors B-a working alarm C-24 hour security of the following:

Please sign here to confirm that you understand this condition

Will the property to be insured exposed to any special hazards? Yes No

If Yes, please describe:

RENTAL REIMBURSEMENT EXTENSION OPTION: Yes No Provides coverage for rental expenses in the event of loss or damage to the named insured’s Equipment for which indemnity is provided under the Performers and Entertainers program. The Insurer will pay as the result of loss of use of such equipment for Expenses necessarily incurred for the rental of a substitute piece of equipment. SUBJECT TO CERTAIN CONDITIONS

Have we insured this risk previously: Yes No

If Yes, please provide policy number:

Has any insurance company declined or cancelled coverage: Yes No

Loss History:

General Comments:

Applicant Name:

Address:

City, Province: Postal Code:

Telephone: Fax:

Email Address:

Signature:

Performer Liability and Miscellaneous Property Application ~ Client Submission For the purposes of the Insurance Companies Act (Canada), this document was issued in the course of Lloyd’s Underwriters’ insurance business in Canada.