Special Event Liability

The exhibitors and concessionaires Special Event Program coverage defends and indemnifies you for alleged negligence resulting in bodily injury, property damage or personal injury.

Only special events qualifying under program guidelines will be quoted under this program.

Special Event QUOTATION REQUEST FORM

REMINDER - Fields marked with an asterisk( * ) require a response.

Contact Information
Contact Person's Name:*
Telephone #, including area code:*		()-
Fax #, including area code:*		()-
E-Mail address:*
Organization Name:*
Address:*
Organization Address (other; e.g., suite)
City, State, and Zip Code of business:*		,

Event Information
Detailed description of your event, (e.g., indicate a specialty or specific theme, etc.):*
Event Title *
Organization's URL *

Coverage Information
Have you ever had insurance for this type event?*		Yes No
If yes, what company?
What was the premium range?
What amount of liability coverage is needed? *
When do you need coverage to start? *
Include an umbrella policy quote if available? *		Yes No
If yes, please select a limit.

Special Event Information
Please complete the following information. *
Does any part of the event include an Activist Rally, March or Literature distribution? *		Yes No
Does any part of the event include Competitive Athletic activity? *		Yes No
Does any part of the event include a Parade? *		Yes No
Does any part of the event include Rodeo activity? *		Yes No
Does any part of the event include Overnight activity? *		Yes No
Does any part of the event include an activity requiring the "Sale of Liquor" and requiring "Liquor Liability Coverage"? *		Yes No
Does any part of the event include Aircraft or Hot Air Balloon? *		Yes No
Does any part of the event include Fireworks? *		Yes No
Does any part of the event include Amusement Devices? *		Yes No
Are you required to provide an "Additional Insured" endorsement to the Leaser of the Premises? *		Yes No
Are you required to provide an "Additional Insured" endorsement to the Event Sponsor? *		Yes No
Are you required to provide an "Additional Insured" endorsement to Volunteers? *		Yes No
Note: No other parties can be named as additional insured.
Choose one of the following event types: *
What is the projected attendance for this future event? *
Please provide all of the following information for the "Additional Insured": *
Name
Title
Organization's Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
County
Work Phone Number
FAX Number
Please provide the name of the facility where the event will take place. *
Please provide the location of the facility where the event will take place. *

Claims History
Have you or your organization had any claims in the past 3 years for the type of insurance being quoted?*		Yes No
If yes, please provide details of "all claim occurrences in the past 3 policy years," include dates, amounts paid by your insurance company, and description of the claim (include what happened and any corrective actions taken to prevent a reoccurrence of a similar claim).

Congratulations. You have reached the end of our form. If you'd like to submit a comment, provide an explanation of any information you've provided on this form, or give information on additional coverage needed, please do so in the space below. We also invite you to contact us by telephone or fax with more information about your business or your insurance needs.

After you have entered all relevant comments, please click the submit button. Thank you for completing this form, we'll do our best to provide you with a timely quote.

Special Event Liability

Special Event QUOTATION REQUEST FORM

Contact Information

Event Information

Coverage Information

Special Event Information

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