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Applicant Business Name if Applicable:
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Applicant Name
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Mailing Street Address
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City
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State, Zip
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Phone number
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E-Mail Address
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Event location (Facility Name)
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Event Address:
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Event City and County:
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Event’s State and Zip:
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Georgia
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Detailed Description of Event:
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Coverages Dates Begin/End:
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Time of event Begin/End:
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Estimated Total Attendance:
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Event will be held:
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Indoors
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Outdoors
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Average Age of Attendees:
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Crowd Control:
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Ushers
Private Security
Off-Duty Police Officiers
Other
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Will the above be Armed?
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Yes
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No
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Does Event Involve and Hazards?
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Yes
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No
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(Ex: Fireworks, amusement rides/devices, food sales?)
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If yes, provide description:
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Will bleachers or platforms be used?
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Yes
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No
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If yes, are they permanent or portable:
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Permanent
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Portable
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Is there an admission charge?
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Yes
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No
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If yes, home much?
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Is Alcohol being served?
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Yes
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No
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If yes, by who?
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Is Alcohol being sold?
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Yes
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No
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If yes, by who?
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Has this event been held before?
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Yes
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N o
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If yes, these questions are required:
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Was the event insured before?
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Yes
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No
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If Yes, by whom?
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Were there any losses or claims?
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Yes
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No
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If yes, please explain:
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Additional Insured Information:
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First Additional Insured:
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Second Additional insured:
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Name:
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Address:
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City:
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State:
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Zip:
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