About You / Your BusinessLegal Business Name:*Primary Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Contact Name:*Email:* Phone Number:*Year Business Established:*Description of Operations:*QualificationsDoes the any of the production activities occur outside of the United States?:* Yes No Does the production include live gangster rap music?:* Yes No Does the event include any bounce houses or inflatables?:* Yes No Will there be any armed security employed at the event?:* Yes No Are any employees supplied to or from an employee leasing agency (i.e. PEO)?:* Yes No Do you understand that if coverage is provided, only one event will be covered by the policy(s) issued?:* Yes No Does the project involve the following: stunts, pyrotechnics, aircraft, boats, animals, race tracks/courses, helicopters, motorbikes, snowmobiles, ATVs, blanks, squibs, guns or other hazardous activities:* Yes No Has there been any losses or insurance claims in the past 3 years?:* Yes No Event DetailsEvent Type:*Event Name:*Cost/Budget:*Venue Location:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Setup Date:* MM slash DD slash YYYY Event Date:* MM slash DD slash YYYY Tear Down Date:* MM slash DD slash YYYY Average Daily spectators:*Number of Artists / Bands:*Key Personnel Full Name:*Event Description:*Coverage:General Liability (occurrence / aggregate limit):*Excluded$1mil / $1mil$1mil / $2mil$2mil / $2mil$3mil / $3mil$4mil / $4mil$5mil / $5mil$10mil+Rented Equipment (total replacement value):*Excluded$25,000$50,000$100,000$150,000$200,000$250,000$300,000$350,000$400,000$450,000$500,000$550,000$600,000$650,000$700,000$750,000$800,000$850,000$900,000$950,000$1,000,000More than $1,000,000Owned Equipment (total replacement value):*Excluded$25,000$50,000$100,000$150,000$200,000$250,000$300,000$350,000$400,000$450,000$500,000$550,000$600,000$650,000$700,000$750,000$800,000$850,000$900,000$950,000$1,000,000More than $1,000,000Third Party Property Damage:*Excluded$25,000$50,000$100,000$150,000$200,000$250,000$300,000$350,000$400,000$450,000$500,000$550,000$600,000$650,000$700,000$750,000$800,000$850,000$900,000$950,000$1,000,000More than $1,000,000Extra Expense:*Excluded$25,000$50,000$100,000$150,000$200,000$250,000$300,000$350,000$400,000$450,000$500,000$550,000$600,000$650,000$700,000$750,000$800,000$850,000$900,000$950,000$1,000,000More than $1,000,000Liquor Liability*Excluded$1mil / $1mil$1mil / $2mil$2mil / $2mil$3mil / $3mil$4mil / $4mil$5mil / $5mil$10mil+Auto Liability - Hired and Non-Owned:*Excluded$1mil / $1mil$1mil / $2mil$2mil / $2mil$3mil / $3mil$4mil / $4mil$5mil / $5mil$10mil+Auto Physical Damage - Hired and Non-Owned:*ExcludedIncludedWorkers Compensation:*ExcludedIncludedIf Workers Compensation is included, please provide annual payroll for cast & crew:Do you need Event Cancellation Coverage?:* Yes No Would you like a quote for Employee Benefits? i.e. group health, disability, life insurance:* Yes No Preferred Broker*Select BrokerAlec RobertsNick PurselDanny ElisevichPete GybenJacob GaleDaniel BanElizabeth BellNo PreferenceHow did you hear about us?:* Google Referral Yelp Other Who referred you?:*How?:CAPTCHA
