ࡱ> ^`]q` N@bjbjqPqP 7F:: 6666666pDt0hwJL ACCCCCC$h4 gi6swg66555 66A5A55665$ P<[ 5$05 N 55 6IL657,cfgg+ 8d8J^l666666 APPLICATION FOR EVENT CANCELLATION 1. INSURED: Association or Organization holding Event Name  FORMTEXT       Address  FORMTEXT       City  FORMTEXT       State  FORMTEXT       Zip  FORMTEXT       Telephone  FORMTEXT       Facsimile  FORMTEXT       E-mail  FORMTEXT       2. EVENT TO BE INSURED TYPE:  FORMCHECKBOX CONVENTION/MEETING  FORMCHECKBOX With Exhibits  FORMCHECKBOX Without Exhibits  FORMCHECKBOX With Teleconferencing  FORMCHECKBOX TRADE SHOW/EXPOSITION  FORMCHECKBOX Open to the Public  FORMCHECKBOX Not Open to the Public  FORMCHECKBOX CONSUMER SHOW  FORMCHECKBOX Event dependent upon 2 or less speakers OTHER TYPE OF EVENT Details: (Provide a separate attachment if necessary) Full Name of Event  FORMTEXT       Open Dates of Event: From  FORMTEXT       to  FORMTEXT       (inclusive) Is any part of the event to be held in the open, in a tent or in any structure of a temporary nature?  FORMCHECKBOX Yes  FORMCHECKBOX No 3. EVENT FACILITY Name  FORMTEXT       Address  FORMTEXT       City  FORMTEXT       State  FORMTEXT       Zip  FORMTEXT       Do written contracts exist between you and the facility?  FORMCHECKBOX Yes  FORMCHECKBOX  No Please confirm you have made all the necessary preliminary arrangements essential to ensure that a satisfactory event can be held on the scheduled date.  FORMCHECKBOX Yes  FORMCHECKBOX  No 4. FINANCIAL INFORMATION a. Please provide the following information about the event to be insured. ___BUDGETED GROSS REVENUE: $ FORMTEXT       ___BUDGETED EXPENSES: $ FORMTEXT       ___BUDGETED NET INCOME: $ FORMTEXT       b. Does the Gross Revenue stated above represent the entire Gross Revenue of the event and not a portion?  FORMCHECKBOX Yes  FORMCHECKBOX  No c. 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FORMCHECKBOX Yes  FORMCHECKBOX  No 5. PRE-EXISTING POTENTIAL LOSS Are you aware of any circumstances existing or threatened, that may possibly result in a claim under the insurance? If the answer to this question is yes, provide full details on a separate attachment.  FORMCHECKBOX Yes  FORMCHECKBOX  No NOTE: If you become aware of any such circumstances after completing this application and before the date insurance of the Convention commences, you must disclose the circumstance to the insurers immediately to see if the insurance will be affected. PLEASE READ AND SIGN BELOW Signing this Application and Declaration does not bind the applicant or the company to complete the Insurance, but it is agreed that this Application and Declaration shall be attached to and form part of any policy which maybe subsequently issued. I declare that the statements and estimates made herein after due inquiry are true to the best of my knowledge and belief. 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