Weather Application

Client Information
Organization   Contact
Company/Organization:*   First Name:*
Entity Type:   Last Name:*
Address:(No PO Boxes)*   Phone:*
Suite, Floor, ect..:   Email:*
City*      
State Zipcode*    


Event Details
Event Name:*
Event Website:
Venue Name:*
Address:*
Address Additional:
City:*
State, Zipcode*
   
Event Dates  
Event Start Date:* DD/MM/YEAR
Event End Date:* DD/MM/YEAR
Set-up Date:* DD/MM/YEAR
Tear Down Date:* DD/MM/YEAR
If the coverage start date is more than 5 days before the event start date OR the coverage end date is more than 5 days after the event date, please explain:
Description of Event:*
 
Type Of Event:
       
Dates of Event:
Hours of Event

Hours of Coverage

 Daily Limit:
-

-

-

-

-

-

-

-

-

-

Hot Day:  
Rainy Hours:
  
Total Rainfall  
Cold Day:    
Snow fall:    
 

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.