Policyholder InformationName 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Name* First Last Phone*Email* Organization / Event Website Event DetailsName of Event* Desired coverage date (including setup and tear down):Start Date* MM slash DD slash YYYY toEnd Date* MM slash DD slash YYYY Date of Event* MM slash DD slash YYYY Event Start Time* : AM PM AM/PM toEvent End Time* : AM PM AM/PM 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 DetailsAll policies are issued with a $1,000,000 per occurrence.Please select the General Liability Aggregate Limit: $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 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 ExperiencePlease 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 InsuredAdditional Insured 1 Name Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Relationship Additional Insured 2 Name Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Relationship Additional Information & Digital SignatureHow 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 CommentsThis field is for validation purposes and should be left unchanged. Δ
