Regional Insurance | Burning Man Liability Insurance Program

REGIONAL INSURANCE QUESTIONNAIRE
Contact Information
Name* Contact Person*
Legal Entity (if any)
Address*
City, State, ZIP*
Phone* Fax
Email * Website
Numbers of Years Attending Burning Man
General Liability
Event I
Start Date(set-up begins) End Date(set-up begins)
Description of Event
Projected Attendance
Will Participants Climb or Suspend Over 25 Feet in the Air?
Does Your Event Involve Pyrotechnics? If so, please explain
Event II
Start Date(set-up begins) End Date(set-up begins)
Description of Event
Projected Attendance
Will Participants Climb or Suspend Over 25 Feet in the Air?
Does Your Event Involve Pyrotechnics? If so, please explain
Event III
Start Date(set-up begins) End Date(set-up begins)
Description of Event
Projected Attendance
Will Participants Climb or Suspend Over 25 Feet in the Air?
Does Your Event Involve Pyrotechnics? If so, please explain
Event IV
Start Date(set-up begins) End Date(set-up begins)
Description of Event
Projected Attendance
Will Participants Climb or Suspend Over 25 Feet in the Air?
Does Your Event Involve Pyrotechnics? If so, please explain
Property Exposure (If property damage coverage is needed)
Art / Equipment Value
How will you transport equipment to event (i.e. car, trailer, 3rd party shipper)

Do you require a Loss Payee, Evidence of Insurance, or Additional Insured Certificate? If so, please provide the certificate holder's name and address. Please also include any special wording instructions.

877-731-7905