Sports Application
Client Information
Organization Information
Company
Company is required.
Entity Type
Address
Address is required.
Suite, Floor, Etc.
City
City is required.
State
Please Choose One
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
State is required.
Zip Code
Zip Code is required.
Contact Information
First Name
First Name is required.
Last Name
Last Name is required.
Phone Number
Phone Number is required.
Email Address
Email Address is required.
Email is invalid.
Location Information
Location Name
Location Name is required.
Location Address
Location Address is required.
Location City
Location City is required.
Location State
Please Choose One
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Location State is required.
Location Zip Code
Location Zip Code is required.
Estimated number of Attendance, Participants, or Members
Number of Spectators
Number of Participants
Number Of Events
Desired Effective Date
Desired Effective Date is required.
Desired Termination Date
Desired Termination Date is required.
Event Details
Event Name
Event Name is required.
Complete description of event/activity
Complete description of event/activity is required.
Describe security protection
Who contracts security?
Facility
Applicant
Hold Harmless?
Yes
No
Emergency evacuation plan in place?
Yes
No
Qualified medical personnel in attendance
Yes
No
Ambulance service in attendance
Yes
No
Will concessions will be sold?
Yes
No
Will alcoholic beverages be served
Yes
No
Will alcoholic beverages be sold
Yes
No
If yes, estimated receipts
Will concessionaries provide you with certificates evidencing products liability with your organization names as Additional Insured
Yes
No
No Concessionaries
Additional Insureds
Will you need to add any additional Insured?
Yes
No
Fraud Statement
Signing this application does not bind the Applicant or the Company to complete the insurance, but it is understood and agreed that the information contained herein shall be the basis of the contract should a policy be issued. If any of the above questions have been answered fraudulently or in such a way as to conceal or misrepresent any material fact or circumstance concerning this insurance or the subject thereof, the entire policy shall be void.
I/We have read the above and agree that to the best of my/our knowledge and belief same fully represents the true statement of facts.
Fraud Statement must be read and agreed to
Applicant
How did you hear about us?
Preferred contact method
Email
Phone
Fax
Applicant Signature
Applicant Signature is required.
Applicant Title
Applicant Title is required.
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