Company Name:

Entity Type:  Individual   Partnership   Joint Venture   LLC   Corporation

Contact Name:

Work Phone:      Fax Number:

Email Address:

Date(s) Of Event         From:     To:

Time Of Event         From: a.m. p.m.     To: a.m. p.m.

Type Of Event:

Event Name:

# of Participants/Performers:

Participant/Performer Name (s):

Participant/Performer Insurance Required?: Yes   No

Type of Music (for Concerts only):

Estimated Number In Attendance:

Venue Name:   Indoors Outdoors

Venue Address:
                    City: , State: Zip:

Any Armed Security: Yes No

Budget/Cost of Event: $

Brief Description of Event:

Any Stunts, Pyrotechnics, Aircraft, Hazardous Activities, Car Races, Precision Driving,
Mechanical Amusement Devices, Film Production, Rap/Hip Hop, Rock/Metal, Rides, or
Water Activities?      Yes   No

Value of Rented Equipment ($):

Value of Owned Equipment ($):

Date when equipment picked up:
Date when equipment returned:  

General Liability:   $1M   $2M   $3M   $4M   $5M

Liquor Liability Coverage Required? ($1,000,000 limit)      Yes   No

Estimated Liquor Sales ($):

Participants & Spectators Medical:     Include   Exclude

Event Cancellation:     Include   Exclude

Third Party Property Damage:     None   $25,000   $50,000   $100,000

Hired and Non-owned Auto Liability:     Include   Exclude