Location and Applicant Information - Special Event Insurance

Location and Applicant Information (Step 1 of 4)

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Fields marked with an asterisk (*) are required.

College/University:

Location of Covered Event:

Applicant/Name of Group:

Applicant Name:

Type of Operation

Corporation

Individual / Sole Proprietor

Partnership / Joint Venture

Limited Liability Company (LLC)

Other

Are you operating under a Doing Business As (DBA) name?

* Yes No

DBA Name:

Other Type:

Applicant E-mail Address:

Confirm E-mail Address:

Mailing Address #1:

Mailing Address #2:

City:

State:

Zip Code:

Contact Name:

Contact Phone Number:

Extension:

Fax Number: