Event Cancellation Insurance Application

Event Cancellation Insurance Application
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APPLICANT INFORMATION
How did you hear about us?*
Select how you found our website.
Insured Name*
The name of your production company or entity (or individual name if not incorporated) you would like to insure. Use the same name as on your rental quote.
Entity Type*
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*

Confirmation Email
Website
Description of your operations:*

UNDERWRITING QUESTIONS
If the performance(s) or event(s) has/have been held before under the present management or any other, hasthere ever been a loss?*

YesNo
If Yes, please provide full details:*
Has the Applicant sustained any loss or damage during the last five years which would have been covered by thistype of insurance had it been in force?*

YesNo
If Yes, please provide full details:*
Has the Applicant had similar insurance (as applied for herein), declined, cancelled, or renewal refused?*

YesNo
If Yes, please provide full details:*
Are there any other material facts or items of information with regard to the proposed performance(s) or event(s)which should be disclosed? (A material fact is one likely to influence acceptance or assessment of this proposalby underwriters).*

YesNo
If Yes, please provide full details:*

Additional Information, Comments
Additional Information or Comments, if necessary, can be provided.
Would you like to receive our quarterly newsletter?*

YesNo
NY License # BR-1001302

CA License # 0I36156 - dba in CA as New York Film Emporium Insurance Services
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EVENT DETAILS