Language
English (US)
Portuguese (Brazil)
Spanish (Latin America)
Special Event Insurance
Will the insurance be in the name of an individual or a business?
*
Individual
Business
Name
*
Applicant Address (NOT the event address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Event Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What type of event is this? Please give a detailed description. Only the operations listed here will be covered.
Event Start Date
-
Month
-
Day
Year
Date
Event End Date
-
Month
-
Day
Year
Date
How many people will attend?
Is this event open to the public or invite only?
Open to the public
Invite only
Is this event indoors, outdoors, or both?
Indoors
Outdoors
Both
Will alcohol be served?
Yes
No
Does the event last overnight?
Yes
No
Type option 3
Type option 4
Are live animals involved? If yes please explain.
Is swimming involved or any activities involving water? If yes please explain.
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For internal use:
Referral Partner:
Please Select
N/A
Rosa
Luciana/Nextcellent
EZ Auto
Next Car
Other
Customer Language:
Please Select
English
Portuguese
Spanish
Agent Name:
Comments:
Date
-
Month
-
Day
Year
Date
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