Event Insurance Form

Please complete as much of this form as possible.

Contact Information
Name of Event*	A value is required.
Contact Person*	A value is required.
Email Address*	A value is required.
Mailing Address
City
State
Zip Code
Home Phone*	A value is required.
Mobile Phone:

Event Information
Day or Overnight Program?	Day Overnight
Describe any specific sports and/or other activities
Event Date(s)
Event Location Address
City
State
Zip
Approximate Number of participants
Approximate Number of coaches (if applicable)
Number of other staff (if applicable)
Have you had prior coverage?	Yes No
Do you have a waiver? (if yes, please fax a copy to 570-226-1147)	Yes No

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