Entertainment – Accident/Medicaladmin2018-08-20T19:27:33-07:00 Entertainment - Accident/Medical Customer InformationWhat is the name that the insurance will be under?*If you do not have a company, the name on the policy needs to match the name you are using for your vendors, permit offices or any other contracts that you have.Address (No PO Boxes)* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Person* First Last Phone*Email* Enter Email Confirm Email Any prior insurance?*YesNoPlease provide the policy numbers, premiums and expiration dates of your prior insurance:*Any prior claims?*YesNoPlease provide the dates, amounts of the claim(s) and descriptions of what happened:*What date do you want this policy to start?* Date Format: MM slash DD slash YYYY Please provide a complete description of your business operations during the requested policy period.*i.e. film production, sporting activities etc.What date do you want this policy to expire?* Date Format: MM slash DD slash YYYY How many total people do you want to cover?*Please enter a number from 1 to 250.Are there any dangerous activities during the policy period?*YesNoPlease describe any of the situations you selected yes to above.*A dangerous situation will not necessarily result in a denial of coverage, but it may affect the pricing of the policy. An accident during dangerous activities would be excluded unless the information was provided at the time of the application submission.CAPTCHANameThis field is for validation purposes and should be left unchanged.