*Required
 
Applicant Information
 
Applicant First Name*  
Last Name*  
Address*  
City*  
State*  
Zip*  
Daytime Telephone Number*  
Mobile Telephone Number  
Fax Number  

Your Email Address*

 
Honoree's First & Last Name*  
Age of Honoree*  
Who, if anyone, referred you to us?*  

For Insurance Agents & Brokers Only: Brokers Name

 
Event Information
 
Type of Event*  

Date of Event?*

Hours of Event?*

 
Name of Location*  
Address*  
City*  
State*  
Zip*  
Telephone Number*  
Fax Number  
Contact Person (First & Last Name)  
Contact Person Email Address  
Estimated Number of guests attending*  
Are you required to name the site as an Additional Insured?  
If yes, what is their Additional Insured Wording (Found in your rental agreement)  
Underwriting Information
 
List anyone else you need to name as Additional Insured on your policy. Include their name, complete address and how they want to be listed on your policy.  
Is the Honoree on Active or Reserve Military Duty?  
Will Liquor be served at the event?  
Will there be a moonbounce or other inflatable games/devices?



 
Is the Applicant or Honoree aware of any circumstances or conditions that may result in a loss under this insurance?  
If yes, please explain  

Policy Limits

To customize this policy to fit your event's needs, please specify the amount of coverage desired for each option.

 
Personal Liability  
Postponement / Cancellation (The total amount you are spending to put on your event).  
Photographs (Cost to reunite attendees for a re-shoot if negatives are lost, damaged, stolen or not properly developed)  
Gifts (Non-monetary)  
Rented Property (To insure tables, chairs, tents, etc. that you rent or borrow)  
Of the rented property items you have included in the total above, list those items valued $1,000 or more).  
Supply us with all the rented property owner's name and address.  
Special Attire  
Jewelry (Owned, rented or borrowed)  
List all Jewelry items, regardless of value, that you have included in your jewelry limit above. Any item not listed is excluded.  
Application Notes/Additional Information  

Application Warranty & Instructions

I HEREBY WARRANT AND CONFIRM THAT THE ABOVE INFORMATION, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT, AND FURTHER CERTIFY THAT I HAVE READ ALL OF THE QUESTIONS AND ANSWERS OF THIS APPLICATION. I UNDERSTAND THIS APPLICATION IS A REQUIREMENT FOR COVERAGE, A PART OF THE CONTRACT AND EVIDENCE OF MY ACCEPTANCE OF THIS INSURANCE, AND ANY FALSIFICATION OR MISREPRESENTATION WILL BE DEEMED A BREACH OF CONTRACT, VOIDING ALL INSURANCE COVERAGE. IT IS UNDERSTOOD AND AGREED THAT THE COMPLETION OF THIS APPLICATION SHALL NOT BE BINDING EITHER TO THE PROPOSED INSURED OR THE COMPANY UNTIL ACCEPTED BY THE COMPANY OR COMPANIES IN WRITING.

I UNDERSTAND THE PREMIUM THAT I WILL PAY FOR THIS INSURANCE IS FULLY EARNED AND NON-REFUNDABLE.

 
Name of person acknowledging Warranty*  
Date of acknowledgment*  
For Insurance Agents & Brokers Only
 
Your Company Name  
First Name  
Last Name  
Address  
City  
State  
Zip  
Daytime Telephone Number  
Mobile Telephone Number  
Fax Number  

Your Email Address