Special Events Insurance

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CIGNA Domestic

CIGNA International

CIGNA Global Plans

408-286-1111

408-997-7890

CA Lic#

0697055

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COMPANY INFORMATION
How did you hear about us? :
Corporate Name:
Trade Name:
Contact first name:
Last name:
Date of Birth:
Phone Number:
Fax Number:
Email Address:
Website:
Entity Type:
Year Business Started (Month/Year):
Years of Management Experience:
Type of Management Experience:
Mailing Address
Mailing Address:
City:
State:
Zip code:
Location Address
Location Address:
City:
State:
Zip code:

Operation type?	with operators without operators Both
With Operators - Projected Annual Gross Sales:	$
Without Operators - Projected Annual Gross Sales:	$

Desired Effective Date:
Describe your operations- Check all that apply:	Backyard Birthday Parties Parks Corporate Events Street Fairs Carnivals Events where you charge each participant Other
Do you or your company operate any Street Fairs, Carnivals or Midways?:	Yes No
Please attach the signage or waiver for your Corporate Events:
Please attach the signage or waiver for Street Fair Events:
Please attach the signage or waiver for your Carnival Events:
Please attach the signage or waiver for your Events where:

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Copyright 2005-2015 Jeewanjee Insurance Agency All rights reserved California Lic # 0697055
1494 Hamilton Ave #101, San Jose, CA 95125