| *Required |
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| Applicant
Information |
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| Applicant
First Name* |
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| Last
Name* |
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| Address* |
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| City* |
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| State* |
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| Zip* |
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| Daytime
Telephone Number* |
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| Mobile
Telephone Number |
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| Fax
Number |
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| Your
Email Address* |
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| Honoree's
First & Last Name* |
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| Age
of Honoree* |
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| Who,
if anyone, referred you to us?* |
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| For
Insurance Agents & Brokers Only: Brokers Name |
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| Event
Information
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| Type
of Event* |
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Date
of Event?*
Hours
of Event?* |
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| Name
of Location* |
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| Address* |
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| City* |
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| State* |
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| Zip* |
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| Telephone
Number* |
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| Fax
Number |
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| Contact
Person (First & Last Name) |
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| Contact
Person Email Address |
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| Estimated
Number of guests attending* |
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| Are
you required to name the site as an Additional Insured? |
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| If
yes, what is their Additional Insured Wording (Found in your
rental agreement) |
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| Underwriting
Information |
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| 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. |
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| Is
the Honoree on Active or Reserve Military Duty? |
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| Will
Liquor be served at the event? |
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| Will
there be a moonbounce or other inflatable games/devices? |
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| Is
the Applicant or Honoree aware of any circumstances or conditions
that may result in a loss under this insurance? |
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| If
yes, please explain |
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Policy
Limits
To
customize this policy to fit your event's needs, please
specify the amount of coverage desired for each option.
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| Personal
Liability |
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| Postponement
/ Cancellation (The total amount you are spending
to put on your event). |
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| Photographs
(Cost to reunite attendees for a re-shoot if negatives
are lost, damaged, stolen or not properly developed) |
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| Gifts
(Non-monetary) |
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| Rented
Property (To insure tables, chairs, tents, etc. that
you rent or borrow) |
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| Of
the rented property items you have included in the total above,
list those items valued $1,000 or more). |
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| Supply
us with all the rented property owner's name and address. |
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| Special
Attire
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| Jewelry
(Owned, rented or borrowed) |
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| List
all Jewelry items, regardless of value, that you have included
in your jewelry limit above. Any item not listed is excluded. |
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| Application
Notes/Additional Information |
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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.
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| Name
of person acknowledging Warranty* |
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| Date
of acknowledgment* |
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| For
Insurance Agents & Brokers Only |
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| Your
Company Name |
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| First
Name |
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| Last
Name |
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| Address |
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| City |
|
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| State |
|
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| Zip |
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| Daytime
Telephone Number |
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| Mobile
Telephone Number |
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| Fax
Number |
|
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| Your
Email Address |
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