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408-997-7890
CA Lic#
0697055
 

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Client Details
Please answer all questions to prevent a delay in processing your quote request.

All Fields with * are Required.
Proposed Policyholder
Name of event:
Description of event:
Location of event:
Location address:
     
     
     
 
   
Contact Person:
*
Phone:
Cell Phone:
Home Phone:
Email Address:
Event start date:
Event termination date:
Desired start date of coverage:
Desired last date of coverage:
Estimated number of vendors at the event:
List email addresses to receive copies of the vendor's certificate(s):
Add more
Insurance Coverage
Choose the general aggregate limit vendors are required to have: $1,000,000.00 $2,000,000.00 $3,000,000.00
$4,000,000.00 $5,000,000.00
Required additional insureds (Who does the vendor need to name): Standard additional insureds are included at no additional cost. If the additional insured needs to receive a copy of the certificate directly and the email address is not listed above, please include below.
Additional No. of insureds:
Additional Insured 1
Certificate Holder Name:
Email Address:
Full Mailing address:
     
     
     
 
   
Additional insured wording instructions:
Relationship: Event Promoter / Organizer Event Venue
Additional Insured 2
Certificate Holder Name:
Email Address:
Full Mailing address:
     
     
     
 
   
Additional insured wording instructions:
Relationship: Event Promoter / Organizer Event Venue
Additional Insured 3
Certificate Holder Name:
Email Address:
Full Mailing address:
     
     
     
 
   
Additional insured wording instructions:
Relationship: Event Promoter / Organizer Event Venue
Additional Insured 4
Certificate Holder Name:
Email Address:
Full Mailing address:
     
     
     
 
   
Additional insured wording instructions:
Relationship: Event Promoter / Organizer Event Venue
Additional Insured 5
Certificate Holder Name:
Email Address:
Full Mailing address:
     
     
     
 
   
Additional insured wording instructions:
Relationship: Event Promoter / Organizer Event Venue
Additional Insured 6
Certificate Holder Name:
Email Address:
Full Mailing address:
     
     
     
 
   
Additional insured wording instructions:
Relationship: Event Promoter / Organizer Event Venue
Additional Insured 7
Certificate Holder Name:
Email Address:
Full Mailing address:
     
     
     
 
   
Additional insured wording instructions:
Relationship: Event Promoter / Organizer Event Venue
Additional Insured 8
Certificate Holder Name:
Email Address:
Full Mailing address:
     
     
     
 
   
Additional insured wording instructions:
Relationship: Event Promoter / Organizer Event Venue
Additional Insured 9
Certificate Holder Name:
Email Address:
Full Mailing address:
     
     
     
 
   
Additional insured wording instructions:
Relationship: Event Promoter / Organizer Event Venue
Additional Insured 10
Certificate Holder Name:
Email Address:
Full Mailing address:
     
     
     
 
   
Additional insured wording instructions:
Relationship: Event Promoter / Organizer Event Venue
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California Lic # 0697055
1494 Hamilton Ave #101, San Jose, CA 95125