Hole-In-One Insurance Questionnaire

Applicant's Name:

Address:

Mailing Address

Address (cont):

Mailing Address - continued

Contact:

Email

Telephone:

Applicant is:

How did you hear about us?

Other

EVENT INFORMATION

Event Name:

Event Date:

Name of Golf Course:

Golf Course Address:

Street, City, State, Zip

1. Total Number of Contestants:

Rows	Amateurs	Professionals
Total Number

2. Please complete questions 2-5 for each prize offered

Rows	Prize 1	Prize 2
2. Prize Value
3. Hole Number
4. Length of Hole (Must be at least 140 yards)
5. Total Shots per Prize

EVENT SIGN (We must receive the request for a free sign at least 10 days prior to the date of the scheduled event.)

Note: Sign will be delivered to your insurance agency.

1. Would you like the insurance company to provide a free sign? (If yes, answer the following.)

1a. Event Name

1b. Date of Event

1c. Hole Sponsor:

1d. Prize Amount ($):

1e. Hole Number

1f. Agency Name

1g. Agency Contact:

1h. Phone Number:

1i. Agency email:

2. Do you want the agency name included on the sign?

Privacy Policy and Terms & Conditions

Consent Checkbox

SIGNATURE

The information I have provided is true and accurate to the best of my knowledge. I have not willfully concealed or misrepresented any material fact(s) or information. I understand completion of this questionnaire does not compel the company to provide coverage.

Signature

Type Full Name as Signature:

Date:

Questions? 877-244-9090
kmorency@morencyinsurance.com

Kevin Morency, Licensed Producer
Morency & Associates Inc.
141 New Shackle Island Rd, Hendersonville, TN 37075
Fax: 615-452-6580

https://sportsprograminsurance.com/