Special Event Liability Application

11875 S. Ridgeview Road, Suite 101 Olathe, KS 66061 Phone / Fax 877-9-SISINC (877-974-7462) E-mail Special Event Liability Application INSURED INFORMATIONA. Insured Company Name (Applicant):1. Contact Name:2. Address:3. City:4. State: Zip Code: Phone:5. Fax: E-mail: No. Years in Years with Present Management: Prior Experience:7. Responsibilities/role of Insured (Applicant) Event : Additional Insured Name9. Address Interest in Event Details: Details: Details: Details: Details: 10. Insured s Loss History: 2016 $ 2015 $ 2014 $ 2013 $ 2012 $ B. Event INFORMATION (Attach a copy of Event brochure and/or flyer to this Application ) 11. Event Name: Event Website Address: Type: (check below as applicable)12. Art & Craft Festival Auction Beauty Pageant/ Concert Chamber of Commerce (see No.)

Specialty Insurance Solutions, Inc. Special Event Liability Application Page 5 11875 S. Ridgeview Road, Suite 101 Olathe, KS 66061

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  Applications, Liability, Special, Events, Special event liability application

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