FIREWORKS SUPPLEMENTAL APPLICATION
1. Name of Insured: ___________________________________________________________________
2. Date(s) of fireworks exposure: _________________________________________________________
3. Specific location of fireworks display(s)___________________________________________________
4. Estimated spectator attendance: ________________________________________________________
5. Name of organization shooting fireworks: _________________________________________________
Provide copy of contract with organization shooting fireworks.
6. Will other coverage be provided? Yes No
If yes, please attach copy of certificate with your name listed as additional insured
(minimum limit of $1,000,000 required).
7. List name of individuals shooting fireworks and their experience (bodily injury to shooters is excluded)
Name Experience
__________________________________ __________________________________
__________________________________ __________________________________
__________________________________ __________________________________
If insured is shooting fireworks, provide copy of current license.
8. Provide diagram of the fireworks display area, detailing the following information:
a. Spectator fencing- distance from launch site to spectators
b. Launch site
c. Direction of Launch
d. Spectator parking lot
e. Concessions area
f. Surrounding areas
9. Describe firefighting equipment on site of event:____________________________________________
_________________________________________________________________________________
10. If no firefighting equipment on site, give distance to nearest fire station: _________________________
Fire protection is: Volunteer Paid
11. Do you have a licensed EMT staffed ambulance on site during all fireworks displays? Yes No
If no, give distance in miles to nearest medical facility: _______ and response time in minutes: _______
12. Have you displayed fireworks before: Yes No
If yes, describe any claims/losses that have occurred and the amount of loss: ______________________
_________________________________________________________________________________
13. Limit of Liability requested (cannot be greater than the event limit): $500,000 $1,000,000
I understand that the insurance company in determining whether to provide a quotation for insurance coverage will
rely on the information contained in the application and all other information being submitted. I hereby warrant,
represent and confirm that, to the best of my knowledge, all information provided is complete, true and correct.
_________________________________ _________________________________
Applicants Signature Producer’s Signature
_________________________________ _________________________________
Applicants Name (print) Producer’s Name (print)
_________________________________ _________________________________
Date (MM/DD/YY) Date (MM/DD/YY)
**If camp personal will be conducting the display please provide copy of license's.
**If an outside company will be conducting the display please provide Certificate of
Insurance naming camp as Additional Insured.