Special Event Accident & Liability Insurance Application

Applicant Information (* required field)

* Contact Name:
* Entity / Organization:	* Contact Email:
* Mailing Address:	* Phone:	-- 999-999-9999
* City:	Fax:	-- 999-999-9999
* State:	Website
* Zip:

Event Details

* Are You Event Holder Performer/Entertainer Vendor/Concessionaire/Exhibitor Mobile Food Vender

* Event Start Date
* Event End Date
* Event Start Time
* Event End Time
* Name of Event
* Is this a Concert?	Yes No
* Is this a Music Festival?	Yes No
	If Yes to Concert or Music Festival, please provide type of music or genre being preformed:
* Event Description	(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)
* Estimated Attendance/Day
* Seating Capacity
* Total number of event days
* Event Location Name
* Event Location Address		City	State
* Does the facility carry liability insurance	Yes No Not Sure
* Is event held at more than one location?	No Yes If Yes, please describe:
* Are overnight accommodations or camping part of the event?	No Yes If Yes, please describe:
* Estimated gross receipts
* Who is responsible for providing Security?

Limits of Liability Requested

$1 Million $2 Million $3 Million $4 Million $5 Million

Optional Accident Insurance

Accident Insurance (Limits up to $100,000 available). Please specify desired amount
What is the number of participants to be covered under accident insurance?
What is the number of spectators to be covered under accident insurance?
Accident Deductible Amount

Add Additional Insured

Name:
Address:
City:
State:
Zip:
Relationship:

Add Additional Insured 2

Name:
Address:
City:
State:
Zip:
Relationship:

Liquor at this Event

* Will liquor be sold at this event?

Yes No

Estimated 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
If yes, please describe?

Prior Insurance Experience

Please fax, mail or email premium and loss experience for the past 5 years to (303) 773-0111.

Please describe any losses over $5,000.00
Has this event been held in the past by the applicant?	Yes No
If yes, number of 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 (303) 773-0111, mail, or email all Lease and Hold Harmless Agreements, brochures of the event and a diagram of location(s) to be used.

Please answer the following question*

Insuring Agreement

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.

* Agree to terms (type name in box)