California insurance from Wise Insurance Agency
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Personal Auto, Homeowners Insurance from Wise Insurance Agency
Personal Auto, Homeowners Insurance from Wise Insurance Agency
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California Insurance Lic #0770590

On-Line Special Event
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!
Your Personal Data

Your Name
Street Address:
City:
State: MUST be California!
Zip/Postal:
E-Mail (REQUIRED):
Phone:
Fax: (Optional)
 
Event Details
Date(s) of Event:
Describe Event in DETAIL:
Event Location (address):
 
Number in attendance:
 
Will food be served? Yes No
If yes to food, describe:
 
Will Alcochol be served? Yes No
If yes to alcohol, describe:
 
Describe security at event:
 
Describe music if any, at event:
 
Is There a Charge to Get In
(called a "cover charge")?		 Yes No
 
If charge, estimate receipts: $
 
Approximate square footage
of location you are using:
 
Name and Address of
Additional Insured, if any
(usually the facility):
 
Send my Quotation Results via: Fax E-Mail
Regular Mail
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Thank you for filling out this form COMPLETELY!

We deem your data submitted as PRIVATE information. Every step has been taken to insure your privacy, security, and to release this information only to you. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release them from any liability should this information be accidentally viewed by others. Also, the insurance carriers reserve the right to issue coverage or not, and we cannot guarantee acceptance of a risk until approved by the company.

Yes, I Agree. Please Rush my Event Quote

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Wise Insurance Agency . 2 California Avenue. San Rafael, CA 94901 . Lic#0770590
Toll Free Phone: 800-939-8730 . Phone: 415-258-9912 . Fax: 415-457-6428
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