Sports Liability & Medical Package Application Step 1 of 5 20% Policyholder InformationYour Company NameThe company name on the policy should be the same legal entity signing the permit/rental contract, if any.----------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 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 NameAddress Mailing Address City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands TelephoneFaxRemember to enter your email address on the previous screen in lieu of your client's email. Event DetailsName of Event*Indoors or Outdoors?*Type of Sport (Camp, Bike Race, Triathlon, Team, etc.)*Event Dates*Event Start Time*Event End Time*Everyone off the grounds by midnight?*YesNoStart Date of Your Policy (First Ste-Up Date)* Date Format: MM slash DD slash YYYY This should be the first date you set up, or the first date you otherwise need your policy to start.What is the Last Date You Will Tear Down & Load Out* Date Format: MM slash DD slash YYYY This should be the last day you will be on location or the last day you would otherwise need your policy.Detailed Event Description*Number of participants Daily (specify the number for each event day)*Number of spectators Daily*For multiple day events, are the participants the same persons each day?*YesNoHow many are under the age of 18?*Age of youngest participant*Age of oldest participant*Do you require participants to sign a Liability Waiver?*YesNoAdmission charge for this event*Budget/Cost for this event*Estimated Gross Receipts* Venue/Site InformationName of Venue*Venue Contact's First & Last name*Venue Contact's Email Venue TelephoneVenue FaxAddress* Mailing Address City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Venue's additional insured wording (found in your rental agreement)You can upload a copy of your permit/rental agreement below.Does the contract require a Primary & Noncontributory endorsement?*Higher rates apply if you need it.YesNoDoes the contract require a Waiver of Subrogation endorsement?*Higher rates apply if you need it.YesNoWhat Per Occurrence limit does the venue require (found in your rental agreement)*What Aggregate limit does the venue require (found in your rental agreement)*Who is supplying security*Is security armed?*YesNoType of Security (Uniform, peer group, ushers, etc.)*How many of each*Type of seating (folding, bleachers, standing, / reserved, general admission*Upload a copy of your permit/rental contractOPTIONAL but will tell us pretty much everything we need to know on how to structure your policy. 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. Provide details (including addresses) of all of your other locations* Additional Event DetailsList anyone else you need named as Additional Insured on your policyAdditional premium will apply. Include name, any specific wording, complete address and relationship to event.Describe First Aid / Medical Arrangements*If you have vendors / subcontractors providing any of these services you should also get named on their policy as an additional insured.Are Participants required to sign a Waiver of Liability?*YesNoAny stunts, pyrotechnics, aircraft, car races, rides or other hazardous activities?*YesNoYour previous Insurance company*Premium PaidList any previous claims*Upload a copy of your event flyer or advertisement (Unless your website shows your ad).Optional. 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? Options That Can Be Added To your PolicyAdditional premium will apply. Would you like a quote for the sale or serving of alcohol? (Liquor Liability)*Recommended if you hold a liquor license, or are receiving ANY monies, including door receipts, from anyone (including caterers, bars, etc.) based on alcohol sales.YesNoAre you directly selling, serving, or sharing income from the sale of alcohol?*YesNoEstimated total liquor sales?*Name on Liquor License*How will you prevent serving minors & the intoxicated?*Describe the training & experience of persons serving alcohol*Average age of attendees?*Average cost of a drink?*Number of patrons you will serve?*Would 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?*Date rented equipment is being picked up* Date Format: MM slash DD slash YYYY Date the last of the equipment is returned* Date Format: MM slash DD slash YYYY 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 / Performer Accident Medical?*This coverage is not a substitution for workers' compensation insurance. See above. YesNoNumber of Daily volunteers?*Number of Daily staff?*Number of Daily Performers?*Describe what duties the volunteers will have*Would you like a quote for Rain (Weather) Insurance?*Requires you to submit at least 10 days in advance of your event date. YesNoCoverage Date(s)*Policy Limit*Coverage Time Begins*Coverage Time Ends*Would you like a quote for Event Cancellation/Non-Appearance Insurance?*Requires you to submit at least 21 days in advance of your event date. YesNoFor outdoor events, is the performance area under a cover/roof? Explain.*Budgeted Total Gross Receipts?*Budgeted Total Expenses?*Would you like a quote for an Annual Policy?*YesNoEstimated number of events over the next 12 months?*Average Attendance per event?*For each event provide us with Event Name/Type of Event/Event Dates/Total Attendance Per Event*EmailThis field is for validation purposes and should be left unchanged.