Page 1 of 2
Personal Information
Name
*
First Name
Last Name
Date of birth
*
Please select a month
January
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Month
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Day
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Year
Home phone number
*
Cell phone number
Which is you preferred phone?
*
Cell Phone
Home Phone
Personal email
*
example@example.com
Which is you preferred email?
*
Personal Email
Work Email
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your preferred method of contact?
*
Phone
Email
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Page 2 of 2
Personal Solutions
Type of Insurance?
*
Please Select
Wedding
Birthday Party
Festival
Marathon
Concert
Hip Hop Concert
Conference
Carnival
Church Event
Protest / March
Trade Show
other
Date of Event ?
*
-
Month
-
Day
Year
Date
Address of Event ?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Alcohol at the event. Please click all that apply.
*
Sold
Served
B.Y.O.B
No Alcohol
Will you make profits on Alcohol sells?
*
Please Select
Yes
No
Is there a ticket charge?
*
Please Select
Yes
No
Number of Guest Attending?
*
Will your event include
*
Stunts
Pyrotechnics
Aircrafts
Animals
Camping/Overnight Stays
Car Races, Precision Driving
Mechanical Devices
Rap/Hip-Hop, Rock/Metal
Rides, Water Activities, Bounce Houses or Inflatables
Does your venue require any of these?
*
Waiver of Subrogation
Primary/Non-contributory Basis
Hired/Non-owned Auto
Additional Insured
Type a question
Type option 1
Type option 2
Type option 3
Type option 4
Name and Drivers License Number of Additional Insured drivers over the age of 18 that will have access to vehicle. ( if no please answer NA
*
For Event Insurance. Please list nature of event and amount needed in coverage. ( Please enter NA if not applying for Event Insurance)
Please upload the following: Drivers License or ID, Declaration Page of current Insurance policy for either home or auto Insurance ( Declaration page list all limits of coverage, exclusion and is commonly found in the first pages of documents)
*
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Authorization and Consent
Please read the attestations below and select a response. Information given is used by JDH Solutions PLLC, for the purposes of assessing eligibility for your quoting, binding, claims, underwriting, investigating, and auditing. Agree to continue application, Disagree if you do not wish to move forward with your application.
Signature
*
Date
*
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Month
-
Day
Year
Date
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