Application for Group Liability Insurance - Per Event

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*

Participation

Mandatory field How many people do you expect to participate in your most popular event?*

Event Details

Please list the names and dates of your events, as well as the full address of the venue. (For a single-day event, enter the same date for start and end.)

Event #1

Event Name

Event Start Date / End Date



Address (Street, City, State, Zip)

Event #2

Event Name

Event Start Date / End Date



Address (Street, City, State, Zip)

Event #3

Event Name

Event Start Date / End Date



Address (Street, City, State, Zip)

Event #4

Event Name

Event Start Date / End Date



Address (Street, City, State, Zip)

Additional Insureds

Please supply the name and full address of each additional venue you wish to cover.

Additional Insured #1 (additional cost of $30)

Additional Insured #2 (additional cost of $30)

Additional Insured #3 (additional cost of $30)

Additional Insured #4 (additional cost of $30)

Premiums

Your total premium is automatically calculated below, based on the dates and insureds you entered above.

"Event day" is counted as a calendar day. For example, a dawn dance that starts on Saturday night and runs until Sunday morning counts as 2 days; a weekend from Friday evening through Sunday morning counts as 3 days.

event days	×   $50   =	$
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.