Special Events

Special Events

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

YesNo
I am a(n)

Insurance BrokerReal Estate AgentLender / Mortgage BrokerOther
Name*

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

Area CodePhone 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*

YesNo
Need a Waiver of Subrogation?*

YesNo
Need Hired & Non-Owned Auto?*

YesNo
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?*

YesNo
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.)*

YesNo
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?*

YesNo
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?*

YesNo
Will you, the insured, your operations, your products, or your event participation have any involvement with cannabis or cannabis-related products?*

YesNo
Your Name & Address (Event Holder)
Your Name*

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

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*

Area CodePhone 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

CityState

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