ONE DAY EVENT WORKSHEET

First Name: Last Name: Business Name: Mailing Address: Mailing City: Mailing State: Select...AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming Mailing Zip Code: Phone Number: Fax Number: E-Mail Address:    UNDERWRITING INFORMATION   Event Address:   Event City: Event State: California 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: Reserved General Admission  Crowd Control & Protection: Ushers Security, Not Armed Security, Armed Off Duty Police, Not Armed Off Duty Police, Armed Police, Not Armed Police, Armed Guard Dogs  Will Bleachers Or Platforms Be Used? yes no  If Yes, Are They: Fixed Portable  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? NoYes  Losses-Claims In The Past 5 Years:  none one two three four five   If Yes, Description, Type & Amount Of each loss-claim Liability Limits Requested: $300,000  $500,000 $1,000,000$2,000,000  Please press the Submit Button ONCE. Then wait for online confirmation of your request. Thank you for your interest.