Your Name Email address

Business Phone Number Cell Phone Number

How would you prefer to be contacted? E-Mail Business Phone Cell Phone

Event Name Date(s) of Event

Time of Event Date includes setup and breakdown? Yes No

What is the location of the event? Who is putting on the event?

Who are the event Sponsors?

Describe Nature of Event

* Note - Participants are excluded, this is third party liability

Are participants required to have their own coverage? Yes No

Is this coverage confirmed in writing? Yes No

Is a release of liability signed by all participants? Yes No

Who wants to be additional insured?

Please include Name and address

This does not constitute insurance coverage being bound. This is only an information gathering form. Coverage must be approved by the carrier and provided to you in writing to be issued!