Special Event Insurance Application, Afford Insurance for Events

Policyholder Information

Name of Policyholder*

The name of the business/organization purchasing the insurance; as it will appear on the policy documents and/or other contract or rental agreements.

Mailing Address*

Street Address City State ZIP Code

Contact Name*

First Last

Phone*

Email*

Organization / Event Website

Event Details

Name of Event*

Desired coverage date (including setup and tear down):

Start Date*

to

End Date*

Date of Event*

Event Start Time*

:

to

Event End Time*

:

Estimated Attendance Per Day*

Estimated Gross Receipts*

Is there a live musical performance at the event?*

Yes
No

Please provide the genre of music and all performing artists:

Description of Event*

Please provide a detailed list of all activities to be held or what will take place for the duration of your event to ensure your event is quoted properly and returned promptly.

Name of Venue/Facility where event is being held:

Event Location Address*

Street Address City State ZIP Code

Does the facility carry liability insurance?*

Yes
No
Not Sure

Is the event held at more than one location?*

Yes
No

Please describe:

Are overnight accommodations or camping part of the event?*

Yes
No

Who is responsible for providing security?*

Insurance Details

All policies are issued with a $1,000,000 per occurrence.

Please select the General Liability Aggregate Limit:

Will liquor be sold at the event?*

Yes
No

Number of attendees consuming alcohol daily?

Are all participating alcohol vendors required to carry minimum liquor liability limits for this event?

Yes
No

Is a liquor license (or liquor permit) required for this event?

Yes
No

Does application have a valid liquor license?

Yes
No

Estimated gross receipts per day alcohol:

Total estimated gross receipts for event for alcohol:

Has the applicant had a liquor loss in the last 5 years?

Yes
No

Please Describe:

Prior Insurance Experience

Please fax, mail or email premium and loss experience for the past 5 years to (720) 836-6399.

Please describe any losses over $5,000.00:

Has this event been held in the past by the applicant?

Yes
No

For how many years?

Has your prior insurance ever been cancelled?*

Yes
No

Has your prior insurance ever refused to renew?*

Yes
No

Do you have a Risk Management Plan?*

Yes
No

Please fax to (720) 836-6399, mail, or email all Lease and Hold Harmless Agreements, brochures of the event and a diagram of location(s) to be used.

Additional Insured

Additional Insured 1 Name

Address

Street Address City State ZIP Code

Relationship

Additional Insured 2 Name

Address

Street Address City State ZIP Code

Relationship

Additional Information & Digital Signature

How did you hear about us?*

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly provides false information in an application for insurance may be guilty of a crime and may be subject to civil fines and criminal penalties. I certify that the above information is true and coverage is not in force until accepted by Anthony Insurance Services, Inc. Coverage is subject to the receipt of payment of the required premium by Anthony Insurance Services, Inc.

Coverage will begin on the date of acceptance or on the date requested, whichever is later. I understand that the premium is fully earned upon policy inception.

Authorized Electronic Signature

Email

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