Application for Group Liability Insurance - Flat Rate

Contact Info

Mandatory field Name of Group*

Mandatory field Contact Person*

Mandatory field Phone*

Mandatory field Email*

Mandatory field Address*

Mandatory field City / State / Zip*

Events Covered

Mandatory field How many people do you expect to participate in these events for the year?*

Event Locations

Please supply the name and full address of each location where your events will occur. You must specify at least one location. (Click on the + icon to create a new box for each location.)

Additional Insureds

Please supply the name and full address of each additional venue you wish to cover. Naming the hall or site itself as an additional insured party in your certificate of coverage is usually not necessary unless the hall owner requests it. (Click on the + icon to create a new box for each additional insured.)

Additional insureds cost $30 each.

Premium

Your total premium is automatically calculated below. The basic coverage price is based on the total number of events per year: $450 for up to 24 events, $550 for 25 or more events. Each additional insured costs $30.

	basic coverage	=	$
	additional insureds	×   $30   =	$
		TOTAL   =	$

Please proceed through store checkout to finish submitting your application. We will contact you if we discover omissions or other problems with your application. Please allow at least 3 weeks for processing; we will forward the certificate of insurance when we receive it from the insurer.