Fields with * are required
Applicant's Name:
Email:
Agent:
Applicant Mailing Address:
Inspection Contact:
Phone Number for Inspection Contact:
Web Address:
Proposed Policy Period:
Insured is:

If other:
Location of Event:
Dates of Event:
Description of Event:

UNDERWRITING INFORMATION
Estimated Attendance per day:
Total for all days event is held:
Gross Receipts: $
Food or beverages sold or served by applicant?
        If yes, provide details:
Alcoholic beverages on premises?
        If yes, are they served by
Seating arrangements- Describe (i.e., permanent, portable, bleachers,chairs, etc.):
        If portable, who does the erection?
Setup - Describe all exposures (i.e., booths, stages, electrical, special effects, etc.):
Who is responsible for the setup?
Security - Describe (i.e., guards - unarmed vs armed, dogs, off-duty police, etc.):
        If guards are used, do they have their own insurance?
Parking Facilities:
    Operated by:
        If others, do they have their own insurance?
Medical Emergencies - How will an emergency be handled?
Are certificates of insurance required from all subcontracted operations?

LIMITS OF LIABILITY REQUESTED
General Aggregate:
Products and Completed Operations Aggregate:
Personal and Advertising Injury:
Each Occurrence:
Fire Damage:
Medical Payments:

CERTIFICATE RECEPIENTS/ADDITIONAL INTERESTS
Name and Address Interest Add'l Ins'd

PRIOR EXPERIENCE AND LOSSES
Prior Carrier Limits Policy Term Loss Information

Has the applicant been cancelled or non-renewed in the last three years? If yes, please explain:

Additional Information