Special Events

Special Events

One or multiple day events
Are you filling this out on behalf your client? *

Yes No
I am a(n)

Insurance Broker Real Estate Agent Lender / Mortgage Broker Other
Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
What Type of Event? *
Where is your event? *
Total days of coverage you need *
Daily Attendance *
Combined no of People
Policy Preference *
Alcohol Coverage *
Coverage Limits *
Damage to Rented Premises: Increase to $300,000 *

Yes No
Need a Waiver of Subrogation? *

Yes No
Need Hired & Non-Owned Auto? *

Yes No
Dates of Coverage Start Date *
Dates of Coverage End Date *
I understand that the dates selected above are the only dates that will be covered by this policy. Each date is midnight to midnight. I have selected all set-up and clean-up days necessary for my event. *

Yes
Are there water activities, amusement devices, inflatables, rides or animals? *

Yes No
Is there camping, sleeping overnight or events past 2 AM? (If going past 12 AM, be sure the following day is included in your date selections above.) *

Yes No
Will your event(s) be a political or activist event, protest, rally or march or could you or your organization's activities result in a political or activist protest, rally or march now or in the future? *

Yes No
Have you or anyone involved in the Event had more than 2 Event Liability Claims/Losses or any Event Liability Claim/Loss valued over $10,000 in the past 3 years? *

Yes No
Will you, the insured, your operations, your products, or your event participation have any involvement with cannabis or cannabis-related products? *

Yes No
Your Name & Address (Event Holder)
Your Name *

First Name Last Name
Your Business Name (optional)
Insured's Address (Your Address) *

Street Address

Street Address Line 2

City State

Zip Code
Phone Number *

Area Code Phone Number
Your Email *
example@example.com
Event Location / Additional Insured 1
Name of Certificate Holder - Location Name *
Certificate Address *

Street Address

Street Address Line 2

City State

Zip Code
Contact Email (optional) *
example@example.com
Signature *

Clear
Should be Empty:

Special Events

Your Name & Address (Event Holder)

Event Location / Additional Insured 1