Prize Indemnity Insurance

Our Prize Indemnity application can help cover the amount of a prize or cash award that your promotion would offer. These types of promotions can help increase the profile of your company/organization/brand in the eyes of the public. There are many potential ways for running a prize promotion, and we have the ability to expand or add to your original ideas.

EXAMPLES OF EVENTS WHICH USE THIS APPLICATION:

Raffles
Half Court Basketball Shots
Prize Lottery

Please be as detailed as possible with the description of how you would like to run your prize promotion. We need as many details as possible (number of participants, prize amount, etc.) so that we can help construct or assist a prize promotion contest that may better suit your original ideas.

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Named Insured

Applicant's Name

Street Address

City

State

Zip

Phone

Fax

EVENT INFORMATION

Type of Event(s) / Promotion(s) / Competition(s) - Please provide full details including contest rules

Dates of Event(s)

Have you any past experience in staging event(s) of this kind? If so, please explain

AFFIRMATION AND SIGNATURE

Declaration

To the best of my knowledge and belief the information provided in connection with this application is true and I have not withheld any material facts. I understand that non-disclosure or misrepresentation of a material fact will entitle the company to void coverage. (A material fact is one likely to influence acceptance or assessment of this application by the companyl if you are in doubt as to what constitutes a material fact, consult your agent.) I understand that signing this application does not bind me to purchase the coverage but agree that should a contract be issued, this form and the statements made hereon shall be the basis for such contract.

I ACKNOWLEDGE

Title

Name of Applicant

Signature of Applicant

Date

BROKER INFORMATION

Name of authorized Agent or Broker

Name of Agency

Agency Mailing Address

Phone

Fax

PRIZE INDEMNITY

Prize Indemnity Insurance

EXAMPLES OF EVENTS WHICH USE THIS APPLICATION: