Event Insurance Quote | Apply for an Event Cancellation Insurance

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I am filling out this application as an:*
IndividualAgent/Broker

1. Association or Organization Holding Event

Name:*

Street Address:*

City:*

State:*

Zip:*

Telephone:*

Fax:

Email:*

Is the above Association a member of the following associations:

IAEE*
YesNo

ASAE*
YesNo

MPI*
YesNo

2. Event to be Insured

Other type of Event Details:

Full Name of Event:*

Open Dates of Event:

From:*

To:*

Is any part of the Event to be held in the open, in a tent, or in any structure of a temporary nature?*
YesNo

3. Event Facility

Name:*

Street Address:*

City:*

State:*

Zip:*

Do written contracts exist between you and the Facility?*
YesNo

Please confirm you have made all the necessary preliminary arrangements essential to ensure that a satisfactory event can be held on the scheduled date.*
YesNo

4. Financial Information

Please provide the following information about the event to be insured:

Budgeted Gross Revenue (no commas or decimals):*

Budgeted Net Income (no commas or decimals):*

Budgeted Expenses (no commas or decimals):*

Does the Gross Revenue/Expenses stated above represent the entire Gross Revenue/Expenses of the event and not a portion?
YesNo

At any time during the past five years, have you had an event that suffered a loss that was covered by insurance?
YesNo

5. Pre-Existing Potential Loss

Are you aware of any circumstances, existing or threatened, that may possibly result in a claim under the insurance?*
YesNo

Note: If you become aware of any 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 acknowledge below:

Submitting 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.

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

Name:*

Title:

Date:

Marsh US Consumer, a service of Seabury & Smith Inc, 540 W. Madison St., Chicago, IL 60661. Or fax to 1-312-627-6172. If you have any questions, please call toll-free: 1-877-451-4003.

* Required

Event Cancellation Insurance Application

Event Cancellation Insurance Quote

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