Fireworks Display Insurance Proposal Form

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1. General Information

Are you an Insurance Broker or Direct Client*
 Insurance Broker Direct Client
Insurance Broker Company Name
Financial Services Authority Number
Insured Company Name (or Insured Person)*
Contact Name*
Please provide a description of the event*
Has the event been held before?*
 Yes No
If yes how many times?

Has the event ever suffered a loss of any kind?*
 Yes No
If Yes please provide details
Please state the name, address and type of venue?*
When does your event start (date)?*
When does your event finish (date)?*
When will you begin setting up your event at the venue (date)?*
When will you complete breaking down your event and leave the venue (date)?*