* = required field

Name *
Email*	Fax 999-999-9999
Street Address*
City*	State*       AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY   Zip Code *
Phone*	999-999-9999
How do you wish to receive your Quotation?*	Email  Fax   Mail
Dates of Event*
Time(s)*
Name of Event*
Location of Event*
Name of Facility*
Does the Facility carry Liability Insurance?*	... Yes No   Limits
Description of Event*
List any Additional Insured Names, Addresses and Relationship to the applicant to be added to the policy.

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Indoors or Outdoors
Is this Event Located Indoors or Outdoors?   Indoors   Outdoors                   If Outdoors, is the Area Fenced or Enclosed? Yes  No
Parking
Are you Responsible for Parking?  Yes    No                   If Yes, Square Footage of Parking Area
Scope of the Event
Seating Capacity		Price of Admission
Estimated Attendance per Day		Estimated Gross Receipts
Number of Tickets Printed		Estimated Total Payroll
Number of Tickets Sold do Date
Limits of Liability Requested
General Aggregate		Medical Payments
Products Aggregate		Fire Damage
Each Occurrence		Personal / Adv Injury

Will there be any Exhibitions, Demonstrations, Parades or Pageants?Yes  No                   If Yes, Describe

Seating Are Seats of Temporary or Permanent Construction?  Temporary   Permanent   Both   N/A Is Seating Reserved or General Admission? Reserved   General Admission Both N/A Describe Type of Seating Provided (Bleachers, Folding Chairs, etc.)   Event Setting   If the Event is Outdoors, does the event end at last ninety(90) minutes prior to sundown? Yes  No   If No, is there Permanent Lighting over all Spectator Areas and Parking Lots?  Yes   No   Stage If a stage is involved, is the Stage of Temporary or Permanent Construction? Temporary   Permanent   Both   N/A   If Temporary, Who is Responsible for Set Up of the Stage?     If other than Applicant, is a Certificate of Insurance Provided?  Yes  No   If other than Applicant, is Applicant Named as an Additional Insured?  Yes  No   Lighting Is Temporary Lighting involved? Yes  No   If Yes, Who is Responsible for Hook Up of Lighting?    If other than Applicant, is a Certificate of Insurance Provided?  Yes   No   If other than Applicant, is Applicant Named as an Additional Insured?   Yes   No   Tent Is a Tent Involved? Yes   No   If Yes, Who is Responsible for Set Up of Tent?    If other than Applicant, is a Certificate of Insurance Provided?  Yes   No   If other than Applicant, is Applicant Named as an Additional Insured?   Yes   No   Ushers Are Ushers used for Seating Purposes? Yes   No   If Yes, Who is providing the Ushers?   If other than Applicant, is a Certificate of Insurance Provided?  Yes   No   If other than Applicant, is Applicant Named as an Additional Insured?   Yes   No   Vendors or Trade Booths What is the number of Vendors or Trade Booths?   What Goods are to be displayed? Are all Goods Finished Products or Demonstrations? Finished Products   Demonstrations   Both Are there any Cooking Demonstrations? Yes   No Are Vendors or Trade Booths Required to Provide a Certificate of Insurance?   Yes   No   Advertising How is Advertising being used at the Event?   Food & Drinks Who is Providing the Food and/or Drinks?   If other than Applicant, is a Certificate of Insurance Provided?  Yes   No   If other than Applicant, is Applicant Named as an Additional Insured?   Yes   No   Liquor Is Liquor to be Sold at this Event? Yes   No If Yes, Complete the following Questions if you would like a Quotation for Optional Liquor Liability Coverage.   Estimated Number of Attendees Consuming Alcohol Daily         Is Applicant the Sole Vendor of Alcohol at the Event?  Yes   No         If No, please list the Number of Vendors Serving Alcohol               Are all Participating Alcohol Vendors required to carry Minimum Liquor Liability Limits for this Event?   Yes   No   Will Alcohol be Dispensed by a Professional Bartender?   Yes   No         If No, Describe How and By Whom Alcohol will be Dispensed         Describe Training and/or Experience of Persons Serving Alcohol         What measures are in place to Prevent Service of Alcohol to Minors and/or Intoxicated Persons?         Is a Liquor License Required for this Event? Yes   No         Does Applicant have a Valid Liquor License?   Yes   No   Number of Bars or Areas at which Alcohol will be Dispensed at this Event               Is Alcohol Consumption Confined to this (these) Areas?   Yes   No         If No, please Describe          Will there be an Open Bar? Yes   No         Will Alcohol be Sold by the Drink? Yes   No         Cost per Drink         Is BYOB Permitted? Yes   No   Will Food be Sold or Served with the Alcohol?  Yes   No         If Yes, Describe Food Available   Estimated Gross Receipts per Day: Alcohol           Food       Total Estimated Gross Receipts for Event: Alcohol           Food       Has the Applicant Received any Fines or Citations in the Last 5 Years?   Yes   No         If Yes, Describe    Has the Applicant had a Liquor Loss in the Last 5 Years?   Yes   No         If Yes, Describe          Cooking   Are there Cooking Facilities on the Premises? Yes   No   If Yes, What type of Fire Protection is Present?   Overnight Accommodations   Is the Applicant Providing any Overnight Accommodations such as Camping?  Yes   No   If Yes, Describe    Security   Who is Responsible for Providing Security?   If other than Applicant, is a Certificate of Insurance Provided?  Yes   No   If other than Applicant, is Applicant Named as Additional Insured?  Yes   No   Is the Security Provided Armed or Unarmed? Armed   Unarmed   If the Event is being held on a Street or Other Public Place of Vehicular Access, What Protection is being Used between the Street and the Sidewalk?    Parade   Does the Event involve a Parade? Yes   No   If Yes, How many Units will there be?   (each float, band, or car is a unit)   Will Anything be Thrown from the Units? Yes   No         If Yes, What will be Thrown from Units?   What is the Length of the Parade in Blocks?    Length of Time:   Estimated Number of Spectators     Fireworks or Pyrotechnics   Are Fireworks or Pyrotechnics to be Used? Yes   No   If Yes, Describe    Hold Harmless Agreements   Is the Applicant Signing any Hold Harmless Agreements?  Yes   No   If Yes, With Whom and What Responsibilities?  A Copy of the Agreement(s), if available, should be faxed to (630)393-5666 or emailed to info@dhcins.com after you submit this request. Is the Applicant being Held Harmless by Others?  Yes   No   A Copy of the Agreement(s), if available, should be faxed to (630)393-5666 or emailed to info@dhcins.com after you submit this request.   Prior Experience   Has this Event been held in the past by the Applicant? Yes   No   If Yes, for how many years?    Describe any Losses over $5,000.00   Has your Prior Insurance Ever Been Cancelled? Yes   No Has your Prior Insurance Ever Refused to Renew? Yes   No Do You have a Risk Management Plan? Yes   No       After you submit this Request, please fax or email the following items: Premium and Loss Experience for the Past 5 Years Copies of Leases and Hold Harmless Agreements Brochures of the Event Diagram of Location(s) to be used Fax:   (630)393-5666          Email:  info@dhcins.com