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.

Liability for Performers/ Entertainers Including Miscellaneous Property DIRECT CLIENT SUBMISSION

Suite 200, 1400 - 1st. Street SW Calgary, AB T2R 0V8

T: 1-800-661-1608 F: 403-261-3903 E: alberta@palcanada.com

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

Actors After Dinner Speakers Art and Craft Skills Art Consultancy Artists Arts Lecturers Athlete or Athletic Performers Authors Balloon Artist Basket Weavers Belly Dancer Cameos Caricaturist Cartoonist Celebrity Look-Alike Character Shows Cheerleading Chocolate Fountain Choirs Comedians Community Artist

Composers Computer Art Concept Visualization Corporate Entertainment Costume Characters Dance Troupe Dancer Disc Jockeys (NOT in nightclub) Dough Modeling Drama Club Drawing Flower Arrangements Gymnastics Hair Braiding Hair Extensions Hair Painting Hair Wrapping Hairdressers Hula Hooping Human Statues Impersonator / Impressionist

Jazz, Folk or Classical Band Karaoke Kissogram Kite Lasso Lecturers Lookalikes Master of Ceremonies / MC's Maypole Dancing Meet and Greet (book signing/autographs) Mime Artists Museum Educator Music Teachers Musician (individual-not band) Nail Art Organist Origami Painter (not construction) Pantomimes Performance artist

Photo Booth Photographer / Photography Poet Preacher Public Speaking Puppeteers Quizmasters Rangoli Researchers Resident Entertainer Ribbon Twirling Ringmaster Role Player Sculptors Silhouette Artist Singing teacher Singers Songwriter Speech Teacher Stage Performer Stand Up Comedy Inc. Props

Storytelling Strongmen Table Top Games (Non-Alcohol) Tap Dance Teacher Textile Artists Theatrical Props Theatrical Stage Group Toastmasters Tour Guides Town Crier Ventriloquist Videographer Viking Characters Vocalists Voice Coach Walkabouts Writer Yo-Yo

Category II - SUBMIT FOR QUOTE Category III - SUBMIT FOR QUOTE Acrobats Airbrush Astro Jacks Balancing Acts Bed of Glass Bed of Nails Bicycle Board Breaking Body Art Body Brush Art Burlesque Acts & Striptease Busker Cabaret Act Carnival Performers Childrens Entertainers Choreographer

Circus Performers Excluding fire, knife, Clown Contortionist Cosmetic Make-up Cycling Acts (Trick Cyclists / Unicyclists) Devil Sticks Face / Body Painter Globe Walking Henna Artist Holiday Characters (Santa/Elf) Juggler Limbo Dancing Low Wire Acts

Makeup Artists Martial Arts display Mural Work Physical Theatre Plate & Ball Spinning Poi Sticks Re-Enactment Artist Rola Bola Skateboard Tricks Tattoos - Airbrush Tattoos - Glitter Tattoos- Henna Tattoos- Temporary Wedding Decorator Whip Cracker

Animal Act Performers (Excluding dangerous animals) Escapologist Fakir Fortune Tellers Glass Walking Historical Enactments Mediums Mobile Casino Palm Reading Rap or Hip Hop Rock or Pop Band Tarot Card Reader

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 IV - SUBMIT FOR QUOTE *Supplementary Questionnaire may be required Aerial Performers* Angle Grinding Performers (outdoor only) Unarmed Combat Display Arrow Breaking Blacksmith Demonstration (outdoor only)

Bubble & Smoke Machines Carving (knife, chain saw, wood, ice, etc) Chain and Pole Swinging Chinese Pole (aerial ) Clown Car Fire Acts (outdoor only)*

Fire Acts Eaters Breathers* (outdoor only) Fire Acts Jugglers (outdoor only)* Glass blower High Wire Acts* Hypnotist*

Illusionist* Inflatables Magician* Mind Reading* Mini Bike Sleigh/Wagon Rides Snake Charmers

Spiritual Healing* Sword Dance Sword Fighting Sword Swallower Tight Rope Artist* Trapeze Artists*

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 of the following:

A- locked doors B-a working alarm C-24 hour security

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.