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Short Term Event Insurance Applicant Individual Corporation Partnership joint Venture Email Limits of Liability Requested General Aggregate Products & Completed   Operations Aggregate     Estimates attendance Estimates participants Maximum capacity at   location of event Sales Detailed description of event Indicate approximate age bracket of public attending event Will event will be held in California Alabama Arizona Colorado Connecticut Delaware Florida Georgia Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Nevada New Hampshire New Jersey New Mexico New York North Carolina Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina Tennessee Texas Vermont Virginia Washington Wisconson Indoors Indicate seating Reserved %   General admission %   Will event be held Outdoors Have local health department codes beendetermined regarding restroom facilities? Yes No   Crowd control, type and approximate number of:   Ushers   Private security   Off-duty police   Guard dogs   Does applicant have Worker's Compensation coverage in force? Yes No   Does applicant lease employees? Yes No Does applicant have previous experience in these type of events? Yes No     if yes please give number, dates,etc.   Is liquor served or sold by others?   Will first aid facilities be provided by applicant? Yes No Have certificates of insurance been obtained from operator? Yes No   PROPOSED EFFECTIVE DATE from   to   If you have already been given a quote, entering the figure here may help you get a better deal -

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