February 23, 2012
Casswood Insurance Agency, Ltd.
Special Event Quote Information
Please complete this form as completely as you can. Having all the information "upfront" allows us to make sure we get you the coverage you need.
 
 General Information
  Contact Name *
  Email *
  Customer Name *   Help
  Address
  City
  State
  Zip
  County
  Business Phone *   Help
  Fax
 
 Business Information
  Are you a *
  Do you have any employees and/or volunteers? If yes please indicate how many. Yes  No 
  How long in Business? (yrs)
  Do you sell products? * Yes  No
  Please give a brief description of your business, clientele and products
 
 Event Information
  Event Name *   Help
  Event Mailing Address *
  Event Mail Address 2
  City, State Zip *
  Event Date(s) *   Help
  Expected Attendance   Help
  Venue Name *
  Venue Location Address *
  Venue Address 2 *
  Venue City, State Zip *
  Will this event include any performance by celebrities, or will it be attended by celebrities? Yes  No
  If you answered yes to the previous question, please provide us with the names and date of appearance.
  Will there be any use of fire, pyrotehnics or activities that take place on or in the water? Yes  No
  Will there be any armed security guards? Yes  No
  Will you be serving liquor at this event?
  If you answer yes we will include Liquor Liability in your quote.		 Yes  No
  Value of Rented Equipment   Help
  Other Property (specify)
 
 Insurance Information
  Annual Gross Sales: (before taxes)
  Annualized Payroll
  Liability Limits Requested/Required *
  Do you need to have the event or venue listed as an Additional Insured(s)?
  Please use the Notes area below to provide the name, address and fax number for the certificates.		 Yes  No
  Are you interested in any of these additional coverage * Participants Medical
Event Cancellation
Spectators Medical
Hired & Non-owned Auto Liability
Extending Coverage to Vendors
None
  Notes
  Add additional information and list your ceritificate holders.
  Describe any claims you've had in the past 5 years
  * indicates required fields
 
  Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application, a down payment and confirmation from the insurance carrier. Completing this form does not provide any coverage, nor is it an offer to provide coverage.
 
© 2010 All Rights Reserved Casswood Insurance Agency, Ltd., New York - California, CA LIC 0C21643 (518) 373-8700 / (800) 972-2242
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