Expoplus - Application

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To receive your personalized estimate for Event Cancellation Insurance, please complete this online form. A licensed Marsh representative will contact you personally to discuss your needs and design a plan that best fits the needs of your event.

If you prefer to fax or mail your request, click here to download an application. If you are a resident of Canada please call 1-800-265-6676 for an application.

I am filling out this application as an * Individual Agent/Broker

Agent or Broker Contact Information (Individuals do not need to complete)

Name		Agency
Telephone		Email

1. INSURED: Association or Organization Holding Event

Name *	Zip *
Address *	Telephone *	(000) 000-0000
City *	Facsimile
State *	Email *

2. EVENT TO BE INSURED:

a. Event
CONVENTION/MEETING	With Exhibits	Without Exhibits	With Teleconferencing
TRADE SHOW/EXPOSITION	Open to the Public	Not Open to the Public
CONSUMER SHOW	Event dependent upon 2 fewer speakers
OTHER TYPE OF EVENT Details:
b. Full Name of Event:
c. Open Dates of Event: From to (inclusive of lease dates)
d. Is any part of the Event to be held in the open, in a tent or in any structure of a temporary nature? Yes No
If the answer to this question is "Yes", please provide full details:

3. EVENT FACILITY:

Name	State
Address	Zip
City
a. Do written contracts exist between you and the Facility?		Yes No
b. Please confirm you have made all the necessary preliminary arrangements essential to ensure that a satisfactory Event can be held on the scheduled date.		Yes No

4. FINANCIAL INFORMATION:

a. Please provide the following information about the Event to be insured.
i. BUDGETED GROSS REVENUE:
ii. BUDGETED NET INCOME:
iii. BUDGETED EXPENSES:
b. Does the Gross Revenue stated above represent the entire Gross Revenue of the Event and not a portion?			Yes No
c. At any time during the past 5 years, have you had an event that suffered a loss that was covered by insurance?			Yes No

5. PRE-EXISTING POTENTIAL LOSS:

Are you aware of any circumstances existing or threatened that may possibly result in a claim under the insurance?	Yes No
If the answer to this question is "Yes", please provide full details:
NOTE: If you become aware of any such circumstances after completing this Application and before the date insurance for the Event commences, you must disclose the circumstances to the insurers immediately to see if the insurance will be affected.

PLEASE READ AND SIGN BELOW:

Signing this Application and Declaration does not bind the applicant or the underwriter to complete the Insurance, but it is agreed that this Application and Declaration shall be attached to and form part of any policy subsequently issued.

In this transaction, Marsh is acting as the exclusive insurance agent and program manager for certain Underwriters at Lloyd's London (“Insurer”) for this type of coverage, and not as your insurance broker. As the agent for Insurer, Marsh will perform all of the functions necessary to underwrite, quote and, upon your acceptance, issue this insurance coverage for your event.

I declare the statements and estimates made herein after due inquiry are true to the best of my knowledge and belief.

Name *		Signature
Title		Date

Please print for your records.

Marsh Affinity Groups Services, a service of Seabury & Smith, 1440 Renaissance Drive, Park Ridge, IL 60068-1400.
Or fax to 1-847-493-4221. If you have any questions, please call toll-free: 1-800-323-2106 ext.34271.