Is liquor served (given away) at this event, not SOLD in anyway? Yes No Is liquor to be sold at this event? Yes No If yes, does the entity selling the alcohol have a state issued permit/license? Yes No If yes, is there a liquor liability policy in-force? Yes No If yes, is the applicant named as an additional insured? Yes No Is the applicant providing any overnight accommodation such as camping? Yes No If yes, please describe: Who is responsible for providing security? Has the event ever been held in the past by the applicant? Yes No If yes, for how many years? If yes, please describe any losses or claims in the last three years: Has your insurance ever been cancelled? Yes No Has your insurance ever refused to renew? Yes No Standard Limits of Liability $3,000,000 General Aggregate $1,000,000 Personal/Adv Injury $1,000,000 Products Aggregate $100,000 Fire Damage $1,000,000 Each Occurrence $ usually excluded Medical Payments If higher limits of liability or additional coverages are required, please indicate: Applicant Signature: Broker Information (if applicable) Printed Applicant Name: Agency Name: Representative: Date: Email: Phone Number: PLEASE FAX OR EMAIL THE COMPLETED FORM WITH A COPY OF YOUR POLICY TO: email: events@eventinsurancenow.com | fax: 503.977.5848
Is liquor served (given away) at this event, not SOLD in anyway? Yes No Is liquor to be sold at this event? Yes No If yes, does the entity selling the alcohol have a state issued permit/license? Yes No If yes, is there a liquor liability policy in-force? Yes No If yes, is the applicant named as an additional insured? Yes No Is the applicant providing any overnight accommodation such as camping? Yes No If yes, please describe: Who is responsible for providing security? Has the event ever been held in the past by the applicant? Yes No If yes, for how many years? If yes, please describe any losses or claims in the last three years: Has your insurance ever been cancelled? Yes No Has your insurance ever refused to renew? Yes No Standard Limits of Liability $3,000,000 General Aggregate $1,000,000 Products Aggregate $1,000,000 Each Occurrence $1,000,000 Personal/Adv Injury $100,000 Fire Damage $ usually excluded Medical Payments If higher limits of liability or additional coverages are required, please indicate: Applicant Signature: Printed Applicant Name: Date: Broker Information (if applicable) Agency Name: Representative: Email: Phone Number: PLEASE FAX OR EMAIL THE COMPLETED FORM WITH A COPY OF YOUR POLICY TO: email: events@eventinsurancenow.com | fax: 503.977.5848
1.ApplicationforPublicLiability.docx