EVENT CANCELLATION APPLICATION –

Name and address of organization applying for insurance:

Name: Click here to enter text.

Address: Click here to enter text.

Name of event: Click here to enter text.

Type of event (check all that apply):

Convention / meeting ☐ Tradeshow/exposition ☐ BBQ Show☐ Other☐ If Other give Details:

Click here to enter text.

How long has this event been held under present management? Click here to enter text.years

Dates of event: Start: Click here to enter a date. End: Click here to enter a date.

Name and location of venue event will be held:

Name: Click here to enter text.

City: Click here to enter text. State: Click here to enter text. Zip: Click here to enter text.

Would you like a quote for Gross Revenue or Expenses? (check one):

Gross revenue ☐ Expenses ☐

List budgeted gross revenue from event: $Click here to enter text.

List budgeted expenses from event: $Click here to enter text.

What percentage of your gross revenue comes from:

Attendees Fees: Click here to enter text. Gate Receipts: Click here to enter text.

Please attach a detailed budget of expenses and gross revenues.

Is the event open to the public? Yes☐ No☐

Does the event include any teleconferencing: Yes☐ No☐

Will the event be held outdoors and/or under canvas? Yes☐ No☐

Will adverse weather preclude the fulfillment of event: Yes☐ No☐

Will the venue require construction work? Yes☐ No☐

Have all necessary arrangements for the successful fulfillment of the event been made? Yes☐ No☐

Have all necessary licenses, visa, and/or permits been obtained and have all contractual arrangements been confirmed in writing? Yes☐ No☐

Do the sums represented in question #7 represent the full extent of your financial responsibilities? Yes☐ No☐

Has the event to be insured ever sustained an insured loss? Yes☐ No☐

Would the non-appearance of any individual preclude the successful fulfillment of the event? Yes☐ No☐

Is the applicant aware of any circumstances, actual or threatened, that may possibly result in a claim under this insurance? Yes☐ No☐

DECLARATION

To the best of my knowledge and belief, the information provided in this application, whether in my own hand or not, is true and I have not withheld any material facts. I understand that nondisclosures or misrepresentation of a material fact will entitle the company to void the insurance. I understand that signing this Application does not bind me to complete the insurance but agree that should an insurance policy be issued, this Application and the statements made therein shall form the basis of the insurance.

PRINT NAME: Click here to enter text. TITLE: Click here to enter text.

SIGN NAME: ____________________________________ DATE: Click here to enter a date.