FAST AND EASY SPECIAL EVENT LIABILITY PROPOSAL FOR BUSY PEOPLE

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1

FIRST NAMEFirst Name

LAST NAME

Today's Dateof appointment

Mailing Addressyour full name

Unit #your full name

Cityyour city

STATE

CA

ZIPZIP

CELL PHONECELL PHONE#

ALT PHONE

Emaila valid email

Email again for Accuracya valid email

UNDERWRITING INFORMATION

DBA and/or LEGAL name of applicant. (Do not include "etal", "etc" or similar wording .)your full name

Applicants role & responsibility in the event?your full name

Type of Event

Type of EventBeer Garden/Beer tentMusical/Theatrical performanceConcertsConventions /Trade show/ExhibitFestivalFundraiserMotor Vehicle race/showCompetition or ShowsParadeParty/Social eventIndividual venodr boothPicnicSporting event/tournamentWedding/Wedding receptionOther

Full Name of PERSON, COMPANY, or ENTITY requiring insurance on the event?

Start Date of Eventstart event

End Date of Eventend event

Full location address of the event.

Full Schedule / Description and Purpose of the event? Attach brochure of flyer below.more details

0 / 250

ENTERTAINMENT PROVIDED?Please describe in box to the right

YESNO

If Entertainment provided, describe and include name of performers and acts.more details

0 / 250

IS SECURITY PROVIDED?Please describe in box to the right

YESNO

If yes please describe security provided, and If security is provided by independent contractors, are they required to carry their own insurance?more details

0 / 250

TYPE OF COVERAGE

COVERAGE DESIRED?Commercial General liability onlyLiquor liability onlyCommercial general liability and liquor liability

COVERAGE LEVEL

LIMIT OF COVERAGE?$1,000,000$2,000,000$5,000,000$10,000,000

ESTIMATED TOTAL ATTENDEES PER DAY?your full name

NAME & ADDRESS OF ADDITIONAL INSURED?your full name

ADDITIONAL INSURED'S INTEREST IN THE EVENT?your full name

DESCRIBE ANY CLAIMS IN THE LAST 3 YEARS. IF NO CLAIMS THEN TYPE ........"NONE"more details

0 / 150

GET ME MY SPECIAL EVENT LIABILITY PROPOSAL

Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By clicking the button below you agree to allow our agency to release this information, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy. We take your privacy and data security very seriously!

Fileupload

.......................................... Please Upload Special Event flyer or brochure if available ....................................................

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