Insurance Enrollment Form

Solutions in sync with your mission

So you can focus on changing the world.

Please complete the form below for your short-term performing arts insurance.

Coverage provided

Commercial General Liability:

$1,000,000 each occurrence Bodily Injury and Property Damage
$1,000,000 Personal & Advertising Injury
$2,000,000 General Aggregate limit
$300,000 Damage to Rented Premises
$5,000 Medical Expense

This insurance is good for up to 60 days with a maximum of 1,500 in attendance.

Please Note: Your credit card will be provisionally charged, but coverage cannot be put in force for 2 business days. If for some reason the insurance company denies to issue you a policy, you will be notified and the charges reversed.

If you have any questions, please contact us.

All Fields Required

Contact Information

Contact Name

Name Of Performing Group

Address

City

State

Zip

Phone Number

Email Address

Performance Information

Performance Name/Brief Description of Performance (insert Guide blurb here):

Performance Location (Name of Venue and Location Address):

Number of Shows/Dates of Shows:

What is the number anticipated for attendance? Your event needs to be less than 1500 individuals.

Policy Start Date for Event:

Month

Day

Year

Policy End Date for Event:

Month

Day

Year

Payment Information

Sub-Total $

Processing Fee $

Final Total $

Credit card number

example: xxxx-xxxx-xxxx-xxxx (no spaces)

CVV number

Expiration Date

Name on card

Merchant Services

Optional Receipt

Would you like a receipt emailed to you? If yes, please provide email address below.

Receipt will be mailed to:

Domenick and Associates: Specialty Insurance Brokers

Insurance Enrollment Form

Coverage provided