Sports Application

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Client Information
Organization Information
*Company/Organization:

Entity Type:
*Address:(No PO Boxes):

Suite, Floor, ect..:
*City:

*State - Zipcode:
 

Contact Information
*First Name:

*Last Name:

*Phone:

*Email:


Location Information
Location Name:*

Location Address:*

Location City:*


Location State, Zipcode:*

 
Estimated number of Attendance, Participants, or Members:
Number of Spectators:
Number of Participants:
Number Of Events:
Desired Effective Date:*

Desired Termination Date:*



Event Details
Event Name:*

Complete description of event/activity:*

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
Ambulanceservice in attendance:
Yes No
Will concessions will be sold?
Yes No
Will alcoholoc beverages be served:
Yes No
Will alcoholic beverages be sold:
Yes No
If yes, estimated reciepts
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?


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.


Applicant
How did you hear about us?
Preferred contact method
Email - Phone - Fax
*Applicant Signature:

*Applicant Title: