Special Event Quote

Name
First Last
Entity Type
Business Name / Non-Profit Name (if applicable):
Address
City State ZIP Code
Phone
Email
Type of Event:
Your Roll:
Event Description
Event Starting Date
MM slash DD slash YYYY
Event Ending Date
MM slash DD slash YYYY
Average Daily Attendance:
Number of Participants / Performers
Venue Name :
Venue Address (including city,state, zip code:
Budget: (Total Cost of Event)
Cost of Admission
Event Will Be Held:
Additional Insured Name Additional Insured Address (incl city & zip) Any Special Wording
Are Alcoholic Beverages being Served?
Are you Selling Alcoholic Beverages?
Is Applicant Sole Vendor of Alcohol at Event?
If No, list Other Vendors Serving Alcohol
Are All Alcohol Vendors Required to Carry Minimum Liquor Liability Limits for this Even
Will Alcohol be Dispensed by a Professional Bartender?
If No, Will Alcohol be Self - Serve?
Liquor License number & County Issued (We will need a copy of license - required prior to binding policy)
Any Reported or Potenial Liquor Liability Claims within last 5 Years?
If Yes, provide dates, description, and status of claim(s):
Include A Message:

Barragan Insurance Agency

1132 Suncast Lane Ste 8

El Dorado Hills, CA 95762

Phone: 916-984-9320

Fax: 916-984-8013

Additional Insured Name	Additional Insured Address (incl city & zip)	Any Special Wording