General Information
  1. Name Address Interest
  2. Name Address Interest
  3. Name Address Interest
  4. IMPORTANT: Please note that it is not a requirement to have all the information for Additional Insured prior to quoting/binding. Once coverage is bound we can add Additional Insured to the policy upon written request to our office. Please note that there are certain entities we cannot add to the policy; if you have a specific question about acceptable Additional Insured, please contact our office.

Event Information
  1. Yes No
  2. -
  3. -
  4. * Include setup and teardown dates

  5. Estimated attendance numbers are very important for rating a fair premium on your event. If you do not know the exact attendance, a high and low range will be acceptable. If you still have questions about these numbers, please contact our office.

Past Information
  1. Yes No
  2. Yes No
  3. Yes No
  4. Yes No
  5. Yes No
  6. Yes No
Liability Information
  1. Please note that our standard limits of liability are $1,000,000 occurrence and $2,000,000 aggregate. Most venues/cities/locations require this minimal amount of coverage. We do not offer policies less than $1,000,000 in occurence limit.

  2. $1,000,000 occ / $2,000,000 agg
  3. Please note we have the ability to raise the limits of liability over $1,000,000 occurrence—some venues/cities/locations require this. Selecting Excess General Liability is not advised unless a venue/city/location is requesting higher limits as this will increase the total premium. If you have questions about this, please contact our office.

  4. Yes No
  5. Yes No
  6. $1,000,000 occ / $2,000,000 agg

Liquor Liability
  1. We cannot offer coverage for BYOB (Bring Your Own Bottle) events.

  2. Required Not Required
  3. Yes No
  4. IMPORTANT: If requesting annual Liquor Liability coverage, please include the estimated TOTAL liquor receipts for that time period.

  5. Yes No
  6. Yes No
  7. Yes No
  8. Yes No
  9. Yes No
  10. Yes No
Affirmation and Signature
  1. 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
  2. I hereby warrant and confirm that the above information, to the best of my knowledge, is true and correct, and further certify that I have read all of the questions and answers on this application. I understand this application is a requirement for coverage, a part of the contract and evidence of my acceptance of this insurance, and any falsification or misrepresentation will be deemed a breach of contract, voiding all insurance coverage. It is understood and agreed that the completion of this application shall not be binding either to the proposed insured or the company until accepted by the company or companies in writing.
Broker Information

(804) 754-7610 ~ 8002 Discovery Drive, Suite 415, Richmond, VA 23229 ~