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Special Event Quote

Special Event Coverage Quote

Omni Special Event Insurance Form:

Please complete this form and provide all information requested in this section.

Special Event Coverage Quote Request

Fraternity Name

Chapter

School Name

Chapter Address

City

State

Zip Code

Your Full Name

Phone

Job Title/Position

Email

Event Name

Event Date

Event Type

Athletic

Band/Concert

Community Service

Food/Dinner/Formal

Homecoming

Philanthropy (Fundraising)

Recruitment

Social

Other

This is for:

Event - Additionally Insured

Insurance Policy - School

Insurance Policy - Other

Venue Name

Venue Address, City ST Zip

Cost of Event

Will there be live music?

Yes

No

If so, please indicate name of band or DJ and type of music

Will alcohol be present at this event?

Yes

No

If so, who will be serving the alcohol

Additional Email(s)

Comments

Thank you for contacting us.

We will get back to you as soon as possible.

Gerard J Colistra, President

Omni Insurance Services LLC

12 Mohawk Place

PO Box 474

Amsterdam, New York 12010

gcolistra@omniinsuranceservicesllc.com

518-448-3352 cell

1-833-261-6100 office toll free

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Fraternity Insurance Service

833-261-6100

12 Mohawk Place

PO Box 474

Amsterdam, NY 12010

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