Event Planners Insurance Application Step 1 of 4 25% Policyholder InformationYour Company NameThe company name on the policy should be the same name you put on your contracts with clients.----------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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary Phone Number (Preferably Mobile)*Can this phone accept texts?YesNoClick Yes if you would like reminder texts about your quote & policy.Secondary Phone NumberCan this phone accept texts?YesNoEmail (If you are an insurance broker, use your email & not your clients)* Enter Email Confirm Email obsolete 8-20-19 WebsiteHow many years of experience do you have?*Who referred you to us?Are you a Non-Profit Corporation?YesNoAre you an insurance agent/broker applying for a quote on behalf of your client?*YesNoFor Insurance Agents & Brokers OnlyYour Insurance Agency NameRemember 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 NameAgents Last NameAddressIf 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. 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Or, Save what You've Entered So Far and Continue Later Underwriting InformationEstimated gross sales for the next 12 months*Estimated number of events planned for the next 12 months*Estimated payroll for the next 12 months*Number of employees*What type of events do you plan or organize*Do you sponsor or promote any events?*YesNoDo you operate a retail store?*YesNoDo you own or lease a venue facility?*YesNoDo you operate a staffing or catering service?*YesNoDo you operate a transportation service?*YesNoDo you supply, manufacture or distribute any goods or products?*YesNoDo you perform any design, construction or installation work?*YesNoDo you host events where you profit from ticket sales, merchandise or food?*YesNoDo you sign contracts on behalf of your client?*YesNoProvide full details on any 'Yes' answers aboveUpload a sample contract between you and your clientsAcceptable 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. Or, Save what You've Entered So Far and Continue Later Policy DetailsStart Date of Your Policy*Your policy cannot start any sooner than the next business day after application submission. Date Format: MM slash DD slash YYYY Your previous Insurance company*Premium PaidList any previous claims*Upload any other documents you want us to reviewAcceptable 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? Or, Save what You've Entered So Far and Continue Later Options That Can Be Added To your PolicyAdditional premium will apply. Would you like a quote for Professional Liability? (Errors & Omissions)*YesNoWould you like a quote for Rented/Borrowed Auto Liability?*YesNoNumber of vehicles you will rent or borrow?*Your cost to rent the vehicles?*Are all drivers at least 25 years old?*Any vehicles seat more than 12 persons?*What will the vehicles be used for?*Would you like a quote for Rented &/or Owned Equipment?*YesNoDescription of all equipment*Describe protection / security at principal location*Total Value of Rented Equipment/Sets/Props/Contents?*Total value of Owned equipment/Sets/Props/Contents?*Would you like a quote for Workers' Compensation?*YesNoNumber of workers*Payroll,*Describe workers' duties*Your Federal I.D. Number*Name & Title of an owner or corporate officer*You and all other owners, officers and directors of the company will be excluded from coverage.Social Security Number*Would you like a quote for Volunteer & Staff Accident Medical?*This coverage is not a substitution for workers' compensation insurance. See above. YesNoNumber of Daily volunteers?*Number of Daily staff?*Describe what duties the volunteers will have*PhoneThis field is for validation purposes and should be left unchanged. Or, Save what You've Entered So Far and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.