DHC Insurance, LLC - Sports insurance, Sports team liability insurance, youth sports accident insurance

National Provider of Sports & Entertainment Insurance

PO BOX 948 Warrenville, IL 60555

(888) 288-1829 tel · (630) 393-5666 fax

Wedding and Wedding Reception Insurance Program Application

* = required field

Name of Applicant*

Email*

Fax 999-999-9999

Street Address*

City*    State   Zip Code

Phone*    999-999-9999

Dates of Event*

Time(s)*

Location of Event*

Name of Facility*

Does the Facility carry Liability Insurance?*    Limits

Description of Event*

Estimate Attendance*

List any Additional Insured Names, Addresses and Relationship to the applicant:

Premium Rates and Benefits (Please check all plan numbers that apply.)

$1,000,000.00 Per Occurrence / $1,000,000.00 Aggregate

1. Program Rate 1 Day Wedding < 1,000 in attendance

$250.00

2. Program Rate 1 Day Wedding 1,001 - 2,000 in attendance $295.00

3. Program Rate 3 Day Package < 1,000 in attendance $295.00

4. Program Rate 3 Day Package 1,001 - 2,000 in attendance $345.00

5. Premium cost to increase the general aggregate
          to $2,000,000.00

Additional 5% of total Premium

This summary of coverage and exclusions is no substitute for reading the entire policy. To receive an entire policy, contact DHC Insurance, L.L.C.

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly provides false information on an application for insurance may be guilty of a crime, and may be subject to civil fines and criminal penalties. I certify that the above information is true and coverage is not applicable until accepted by DHC Insurance, L.L.C.

Authorized Electronic Signature*:

PO BOX 948 | Warrenville, IL | 60555 | (888) 288-1829 tel (630) 393-5666 fax

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