Cancellation Application

Policyholder Information
Your Company Name
This is NOT the place to put the event name. You will be asked for that information on the next screen.
----------
Insurance Brokers- DO NOT put your name here. You will be asked for that information on the next screen.
Your Full Name*
Address*
Street Address City State ZIP Code
Primary Phone Number (Preferably Mobile)*
Can this phone accept texts?
- Yes
- No
Click Yes if you would like reminder texts about your quote & policy.
Secondary Phone Number
Can this phone accept texts?
- Yes
- No
Email (If you are an insurance broker, use your email & not your clients)*
Enter Email Confirm Email
Obsolete 8-20-19
Website
How many years of experience do you have?*
Who referred you to us?
Are you an insurance agent/broker applying for a quote on behalf of your client?*
- Yes
- No
For Insurance Agents & Brokers Only
Your Insurance Agency Name
Remember to enter YOUR email address above, NOT your client's email. Otherwise they will receive automatic notifications and our quote instead of you.
Agents First Name
Agents Last Name
Address
If you're one of our regular brokers, you can skip this part. We'll look you up by your name and email. If you're new, or your address information has change, please continue.

Mailing Address City State / Province / Region ZIP / Postal Code Country
Telephone
Fax
Remember to enter your email address on the previous screen in lieu of your client's email.

Policy Limits & Coverage
Gross Revenue from your event*
Gross Revenue: All monies paid or payable to you from every source arising out of the event.
Total Event Expenses*
Total Expenses: The total of all your costs and charges from the planning, preparation and staging of the event.
Do you want a quote on Gross Revenue or just your expenses?*
- Revenue
- Expenses
Do you want to include coverage for Artist/Performer/Speaker Non-Appearance?*
- Yes
- No
Provide details of all persons to be insured: Names, ages, duties.*
Describe their travel itinerary. Where are they traveling from? Method of transportation? Date & time of arrival?*
Are you aware if any of these persons have a history of not appearing?*
Are you aware if any of these persons are suffering any medical condition?*

Venue Information
Name of Venue*
Venue Contact's First & Last name*
Venue Contact's Email
Venue Telephone
Venue Fax
Address*
Mailing Address City State / Province / Region ZIP / Postal Code Country
Will the event venue require any type of construction work? Explain a yes answer.*

Additional Event Details
Your previous Insurance company*
Premium Paid
List any previous losses, insured or not*
Upload a copy of your venue contract and your artist contract.
Acceptable file types: pdf, jpg, gif, png, doc, docx, xls, xlsx. Maximum File Size: 128MB.
Drop files here or

Accepted file types: pdf, jpg, gif, png, doc, docx, xls, xlsx.
Any additional information we need to know?
Comments
This field is for validation purposes and should be left unchanged.

Or, Save what You've Entered So Far and Continue Later

Policyholder Information