Private Event Insurance Application Form

RVNUCCIO & ASSOCIATES INC. - Specialty Insurance Programs and Placements

A. APPLICANT AND HONOREE INFORMATION

01. Today’s Date:

02. Applicant Name:

03. Mailing Address:

04. Applicant Home Phone:

05. Applicant Business Phone:

06. Applicant Fax:

07. Applicant E-mail:

08. Honoree 1 (or Bride) Name:

09. Honoree 1 Address:

10. Honoree 2 (or Groom) Name:

11. Honoree 2 Address:

B. PRIVATE EVENT INFORMATION

12. Private Event Type:

Anniversary Party Birthday Party House Warming Wedding Rehearsal Baby Shower Confirmation Retirement Party Wedding Rehearsal Dinner Baptism Engagement Party Sweet Sixteen Party Wedding Shower Bar Mitzvah Family Party Wedding Bat Mitzvah Family Reunion Wedding Reception

13. Rehearsal Information:

a. Only those private events specifically listed are covered by the policy. Does your private event include a Rehearsal? Yes No

b. Rehearsal Date:

c. Total Attendance:

d. Rehearsal Site Name:

e. Rehearsal Site Address:

f. Is the Rehearsal Site/Venue requiring that you name them on a liability policy as an Additional Insured? Yes No

g. Rehearsal Site Additional Insured Language (if applicable):

14. Rehearsal Dinner Information:

a. Only those private events specifically listed are covered by the policy. Does your private event include a Rehearsal Dinner? Yes No

b. Rehearsal Dinner Date:

c. Total Attendance:

d. Rehearsal Dinner Site Name:

e. Rehearsal Dinner Site Address:

f. Is the Rehearsal Dinner Site/Venue requiring that you name them on a liability policy as an Additional Insured? Yes No

g. Rehearsal Dinner Site Additional Insured Language (if applicable):

15. Ceremony Information:

a. Only those private events specifically listed are covered by the policy. Does your private event include a Ceremony? Yes No

b. Ceremony Date:

c. Total Attendance:

d. Ceremony Site Name:

e. Ceremony Site Address:

f. Is the Ceremony Site/Venue requiring that you name them on a liability policy as an Additional Insured? Yes No

g. Ceremony Site Additional Insured Language (if applicable):

16. Reception/Party Information:

a. Only those private events specifically listed are covered by the policy. Does your private event include a Reception or Party? Yes No

b. Reception/Party Date:

c. Total Attendance:

d. Reception Site Name:

e. Reception Site Address:

f. Is the Reception Site/Venue requiring that you name them on a liability policy as an Additional Insured? Yes No

g. Reception Site Additional Insured Language (if applicable):

17. Is any other person or entity requiring that you name them on a liability policy as an Additional Insured? Yes No

a. Name of Person/Entity:

b. Address of Person/Entity:

c. Additional Insured Language (if applicable):

18. Is any other person or entity requiring that you name them on a liability policy as an Additional Insured? Yes No

a. Name of Person/Entity:

b. Address of Person/Entity:

c. Additional Insured Language (if applicable):

19. Is any other person or entity requiring that you name them on a liability policy as an Additional Insured? Yes No

a. Name of Person/Entity:

b. Address of Person/Entity:

c. Additional Insured Language (if applicable):

C. COVERAGE SECTION SELECTION

20. I am only interested in Personal Liability coverage

21. I am interested in all of the available coverages

D. PROPERTY COVERAGE, LIMIT AND DEDUCTIBLE SELECTION

22. Cancellation Or Postponement Coverage (Optional)

a. Cancellation Coverage
$

b. Change Of Heart Coverage Option
(01) Change Of Heart Limit
$
365 days out

23. Additional Expense Coverage Limit is set at 25% of Cancellation limit

24. Photographs And Video Recording Coverage (Optional)
$

25. Gifts Coverage (Optional)
$

26. Special Attire Coverage (Optional)
$

27. Jewelry Coverage (Optional)

b. Total Scheduled Jewelry Replacement Value $

28. Loss Of Deposits Coverage (Optional)
$

29. Counseling Coverage (Optional)
$

30. Property Coverage Deductible Selection
$

E. PERSONAL LIABILITY COVERAGE, LIMIT AND DEDUCTIBLE SELECTION

31. Personal Liability Coverage Limit (Optional)

$ 500,000/1,000,000
$ 1,000,000/2,000,000
$ 2,000,000/2,000,000

32. Medical Payments Coverage Option (Optional)

$ 1,000.00
$ 2,500.00
$ 5,000.00

33. Personal Liability Property Damage Deductible Selection
$

F. SPECIAL NOTES

34. The underwriter and/or the program administrator reserve the right to accept or reject any application for insurance, any alteration or change request or any request to issue an Additional Insured certificate or endorsement.

35. Any pricing information is subject to change without notice.

36. Weather coverage is available only if the policy is purchased 14 or more days before the date of the first event.

37. The cost of the policy is fully earned and non-refundable if cancelled within 30 days of the date of the first event.

38. Coverage will not be effective and a Certificate Of Insurance will not be issued until the full and correct payment has been received by R.V. Nuccio & Associates, Inc.

39. Only R.V. Nuccio & Associates, Inc. has the authority to bind any coverage under the policy.

40. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject or fines and confinement in prison.

G. APPLICANT/BROKER ACKNOWLEDGEMENT AND SIGNATURE

41. Are you currently a Fireman’s Fund policy holder? Yes No

42. Is the applicant, Honoree 1 or Honoree 2 aware of any circumstances or conditions, which may result in a loss under this insurance? Yes No

If “Yes”, please explain:

43. Do you understand and agree that the cost of the policy is fully earned and non-refundable if the policy is cancelled within 30 days of the date of the first event? Yes No

44. Please tell us how you heard about Weddingsurance®:

Event Site/Venue Google Search MSN Search Yahoo Search Friend Magazine Newspaper Other

45. Applicant/Broker Printed Name and Date:

I understand and agree that by entering my name below, I am effectively signing this application for insurance. Yes No