Camps, Overnight Events, and Sporting Liability

Liability Coverage to Include Participant Third-Party Liability Claims

Contact Name

Contact Person Is

Phone

Fax

Insured Entity Name

Insured is

Street Address

City

State

Zip

Event Location

Name of Event

Facility Name

Address

City

State

Zip

Description of Event

Desired Effective Date

Desired Expiration Date

Event Is

Day
Overnight

Number of Staff/Volunteers Per Day

Number of Participants Per Day

Participants Age 12 and Under

Participants Age 13-15

Participants Age 16-18

Adult Participants

Does your organization currently utilize a waiver of liability form? (if you do not know the answer, select No)

Yes No

Accident medical coverage is required in order to place participant liability coverage.
Accidental coverage will have a deductible and will be noted on your quote.

Include Pricing For

Participants Only
Participants and Staff

Number of Qualified Medical Personnel in Attendance

Number of EMT'S in Attendance:

Will your organization be serving or selling alcohol?

Yes No

If yes, please describe

If sold, does the entity selling the alcohol have a state issued permit/license?

Yes No

Has this event been held in the past by this applicant?

Yes No

If so, were there any losses or claims?

Please Describe

Was there a previous insurance carrier?

Yes No

If so, who?

Additional Insured

(Usually the facility hosting the event)

Name

Street Address

City

State

Zip

Phone

Relationship

Fraud Warning

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties, as well as the withdrawal of such insurance and/or the denial of any coverages and/or claims.

Signed by Applicant

Date

Printed Name of Applicant

Insurance Agent/Broker

If this application is for your customer, please provide your:

Agency Name

Representative

Phone

Event Insurance Now
Phone 877-305-5040
Fax (503) 977-5848
events@eventinsurancenow.com

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