Special Events Quote - Zumach Insurance Agency

COMPANY INFORMATION (Special Events Application )

Business Name or Insured Name *

Type of Business (Sole Proprietor, LLC, INC, Non Profit) *

EIN or SS *

Email *

Phone *

Date Business Started *

What does your business do? Please be detailed

Location Address *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address if applicable

Address Line 1

Address Line 2

City

State

Zip Code

CONTACT INFORMATION

Owner or CEO *

First

Last

Phone *

EVENT INFORMATION

Location of Event *

Address Line 1

Address Line 2

City

State

Zip Code

Entites to be added as Additional Insured

Additional Insured Address

Address Line 1

Address Line 2

City

State

Zip Code

Brief Narrative of Event(s)

Event Start Date

Event End Date

Number of Attendees

Number of Consumers

COVERAGES

Limits of Insurance. Please select a limit

$1,000,000/$2,000,000
$1,000,000/$3,000,000
$2,000,000/$2,000,000
$3,000,000/$3,000,000
$4,000,000/$4,000,000
$5,000,000/$5,000,000

UNDERWRITING (EXPLAIN ALL YES RESPONSES)

Will the event feature firearms? *

Will the event feature fireworks? *

Will attendees be allowed on mechanical rides or devices at the event? *

Will the applicant be named as additional insured on the third party ride vendor's general liability policy?

Are all rides owned and operated by a third party vendor who carries GL limits of at least $1M/$2M?

Does the event include any medical treatment or health screenings? *

Will the event feature overnight camping, or dormitory stays on the event`s premises? *

Provide other helpful details below or all yes responses above.

Confirmation (Enter First and Last Name) I certify that the information provided above is accurate. I understand that wrong information may cause my quote to vary and declination. *

I certify that the information provided above is accurate. I understand that wrong information may cause my quote to vary and declination.

Date / Time

Date

Time

COMPANY INFORMATION (Special Events Application )

CONTACT INFORMATION

EVENT INFORMATION

COVERAGES

UNDERWRITING (EXPLAIN ALL YES RESPONSES)

Location

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