First Name:

Last Name:

Business Name:

Mailing Address:

Mailing City:

Mailing State:

Mailing Zip Code:

Phone Number:

Fax Number:

E-Mail Address: 




Event Address:


Event City:

Event State:


Event Zip Code:

Please Describe The Special Event:

Number of Days Event Will Run:

What Date Do You Expect The Event To Begin:

Estimated Attendance Per Day:

Total Estimated Participants:

What Is The Maximum Capacity Of The Event Location:

Total Gross Receipts For The Event:

Any Celebrities To Be Present?

yes no 

Type Of Seating:

Crowd Control & Protection:

Will Bleachers Or Platforms Be Used?

yes no 

If Yes, Are They:

Does The Special Event Involve Fireworks?

yes no 

Does The Special Event Involve Amusement Rides?

yes no 

Does The Special Event Involve Food Sales?

yes no 

Does The Special Event Involve Alcoholic Beverage Sales?

yes no 

Is This A Sponsored Event?

yes no 

Business License Number, If Applicable:

License Type, If Applicable:

Years of Experience:

How Many Years Have You Operated Under This Business Name?

Have You Uses Any Other Business Name During The Past 5 Years?


Losses-Claims In The Past 5 Years: 


If Yes, Description, Type & Amount Of each loss-claim

Liability Limits Requested:

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