You may submit this form via the submit button below to get a quote if you do not need to send in diagrams or seperate information. 

We MUST have an original signature and premium prior to placing coverage in effect.

You Only have to fill in applicable sections

 
Note: If this is a private event, please CLICK HERE

to proceed to our Wedding and Private Event Application Page

Profit       Non-Profit 1. Name of Applicant: 2. Mailing Address(street, number, city state, zip): 3. E-Mail Address 4. Daytime Phone Number 5.Describe Event: 6.Location of  Event: 7.Date of Coverage:  Date From:  to Hours From:to 8.Coverage: Premises Liability      Products Liability Liquor Liability  Other Describe Other: 9.Limits Desired: Premises Liability  $500,000 $1,000,000 $2,000,000 $5,000,000 $10,000,000 Liquor Liailibity       $500,000 $1,000,000 $2,000,000 $5,000,000 $10,000,000 10.Estimated attendance:  Attendance Per Day:      Total Ave.Age of Attendance 11.Gross Receipts:$How much from alcoholic beverages:$                   Price per  Ticket  $ 12.Liquor Served: Open Bar?YesNo Cash Bar?Yes No Number of Beer Tents 13.Liquor Served by:  Applicant?  Others?  Number of Bartenders? 14.What Type Served? 15.Describe All Entertainment: 16.Additional Insureds and their interest? 17.Is this a part of larger function?Yes No       If Yes,explain: 18.How many years has event been held? 19.Describe all losses/claims past 5 years: 20.Prior Insurance Carrier:             Prior Premium/Rate: 21.Is there Parking?Yes No       If yes,Who is responsible? 22.Area Sq.Ft.       Describe Security: 23.If Security is subcontracted, provide their insurance details:   Animal Rides 1.Provide complete listing of animal rides: 2.Does applicant lead animals as they are being ridden?Yes No 3.Where do individuals ride?On Animal In Cart/Wagon,etc. 4.Are there any height or age restrictions?Yes No Describe: Amusement Devices (Kiddie Type ) 1.Provide complete list of equipment w/photo of each ride.     Properly licensed to state regulation?Yes No 2.Does applicant have documented maintenance schedule?Yes No 3.Are devices stationary?Yes No    If No,describe: Amusement Devices (Other than Kiddie Type ) 1.Operator must have his own insurance and provide certificate of insurance with limits and coverage equal to     or greater than those requested on this application.    Describe rides: Demolition Derby 1.Please provide description of facility with diagram -including type of protection used to protect spectators         from flying debris,placement of barriers to keep vehicles a safe distance from spectators,etc. Dog Races,Horse Races,Horse Shows 1.Please provide diagram of facility. 2.Are spectators allowed in area where animals are kept when not performing?Yes No 3.Do livestock contractors have their own insurance?Yes No Fairs,Carnivals Please provide a complete description of event with diagram indicating location of each exhibit,booth,ride, happening,etc. Fireworks Exhibition 1.Contractor must have his own insurance and provide certificate of insurance with limits and coverage equal to or greater than those being requested on this application. 2.Who will be igniting the fireworks? 3.Any volunteers used to perform duties?Yes No     If Yes,describe: Musical Concert 1.Name of Performers/Groups and type of Music:   2.Do they have their own insurance?Yes No     If yes,details: 3.Is concert indoors?Yes No     If indoors,is it assigned seating? Yes No    If Outdoors,attach diagram of location showing seating,snack bars,restrooms,exits,parking,etc. Parades -(Spectator Liability only ) 1.Provide diagram area of route and spectator area. 2.Are there any animals?Yes No     If yes,describe: 3. Are participants required to have their own coverage?Yes No      If yes,details: Additional Information /Comments:

Applicant Signature:	____________________________________
Date:	____________________________________
Agency:	____________________________________
Agent Signature:	____________________________________

(BE SURE TO PRINT A COPY OF THIS APPLICATION SO THAT YOU MAY MAIL IT ALONG WITH ANY NEEDED DOCUMENTS AND YOUR ORIGINAL SIGNATURE SHOULD OUR QUOTE BE ACCEPTABLE)