Application Form

Contact Information
Name*
Address*	A value for Applications_Address1 is required. A value for Applications_Zip is required. A value for Applications_City is required.
Phone*	A value for Applications_Phone is required.
Email*	A value for Applications_Email is required.

Policy Information

Term
Effective Dates are from the date of application acceptance
and payment through the end of the policy term.

10/1/2024-10/1/2025

Is this a renewal?

Years performing as a Christmas Character?

As a Christmas Character Performer, have you had
any claims filed against you within the past four years?*

Estimated number of appearances from the date
of application through the end of the policy term

Number of Assistants
Member’s Assistant: Mrs. Claus, elf, etc.

Persons other than the member who are assistants

Persons other than the member; Mrs. Claus, elf, etc.

Member as Additional Character
as non-Christmas characters; excluding licensed characters

ADDITIONAL CHARACTER ENDORSEMENT INCLUDES BUT IS NOT LIMITED TO: Clowns; Uncle Sam; Easter Bunny;
Renaissance Fairs; Magicians; Story Tellers
EXCLUSION FOR USE OF LICENSED CHARACTERS WITHOUT THE WRITTEN PERMISSION OF THE LICENSOR ADDED.
Example: Mickey Mouse; Sponge Bob Square Pants; Marvel Super Heroes; DC Super Heroes; Teenage Mutant Ninja Turtles

Yes

Include Property Coverage*

Property endorsement covers props and costumes against direct physical loss up to 10,000. Exclusions apply. A per claim deductible applies.

Yes

Coverage Option*

Option 1 - Description

Option 2 - Description

Abuse & Molestation Coverage is excluded unless background checks on member and member assistants are completed and on file.

Reminder: Please proofread your name and contact information. The policy will be issued with your name and address exactly as it is entered above, and will be sent to your email exactly as it is typed above.

Applicant's Statement and Declarations

The applicant declares to the best of his/her knowledge the information contained in this application and all supplements attached to be true and that no material facts have been suppressed or misstated. The applicant further understands that any false or fraudulent statements or misrepresentations could result in the termination of voidance of any insurance contract issued from the information stated herein.

Payment Information

Quantity	Description	Rate	Total
1	Member – Flat/Fully Earned	$170.00	$170.00
1	Member – Service Charge	$4.92	$4.92
0	Assistant – Flat/Fully Earned	$75.00	$0.00
0	Assistant – Service Charge	$1.94	$0.00
0	Property Coverage	$100.00	$0.00
0	Property Coverage - Service Charge	$2.90	$0.00
0	Additional Character Liability	$75.00	$0.00
0	Additional Character Liability Service Charge	$1.94	$0.00
1	Processing Fee	$6.00	$6.00
		Total	$180.92