SPECIAL EVENT INSURANCE QUOTE

Cooper, Simms, Nelson, & Mosley World Wide Web Site Online Insurance Application


		IMPORTANT NOTICE: Please note that no coverage can be bound using e-Mail, the Internet, or by leaving a voice mail message. All requests must b conducted through our agency with signed applications.


Toll Free: 1.877.644.2766 Providing Insurance Since 1934


SPECIAL EVENT INSURANCE QUOTE		We would like to provide you with a free, no-obligation special event insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

General Information
Business/Company Name:
The entity to be insured is a:
Contact Name:
Address:
City:	State: Zip:
Phone:	Fax:
Email Address:

Event Date / Location(s)

Date(s) of your event:

Event Location (Address):

City:

State: Zip:

Will there be other locations?:

Yes No

(If "yes", list additional locations in comments section below.)

Event Information

How many people will attend event?:

Will admission be charged?:

Yes No If Yes, how much per person?: $

Charges other than admission?:

Yes No

(i.e. food, drink, merchandise etc.)

Estimated total gross income
from all event-related charges:

Will alcohol be served?:

Yes No Serverd by: Your Employees Volunteers

Please describe any entertainment, special exhibitions, organized sporting events, or competition that will take place at event:

Will transportation
or lodging be provided?:

Yes No

Are you required to name additional insureds on this insurance?:

Yes No

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, such as additional event location addresses, etc..., please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.