Artist Liability Application (One Time Event)

IF YOU ARE A VENDOR OR EXHIBITOR PLEASE DO NOT FILL THIS APPLICATION OUT
CLICK THIS LINK FOR VENDOR / EXHIBITOR COVERAGE
Event Information
Name of Event:*
Event Date:*
Venue:*
Address:*
City:
State, Zipcode:
Venue Contact:
Contact Phone:
Contact Email:
Insured Information
Insured Name:*
Address:*
City:
State, Zipcode
Contact:*
Contact Phone:*
Contact Email:*
Insurance Requirements
Additional Info
 


Applicant
How did you hear about CSI Insurance?
Preferred contact method
 Email - Phone - Fax
Applicant Signature:*
Applicant Title:*

FRAUD STATEMENT: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON, FILES AN APPLICATION FOR INSURANCE COMPANY 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 BE SUBJECT TO CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. WARRANTY STATEMENT: I HEARBY 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 CMPANY UNTIL ACCEPTED BY THE COMPANY OR THE COMPANIES IN WRITING.