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THE CALIFORNIA STATE UNIVERSITY  Bakersfield  Chico  Dominguez Hills  Fresno  Fullerton  Hayward  Humboldt  Long Beach  Los Angeles  Maritime Academy

Monterey Bay  Northridge  Pomona  Sacramento  San Bernardino  San Diego  San Francisco  San Jose  San Luis Obispo  San Marcos  Sonoma  Stanislaus

CALIFORNIA STATE UNIVERSITY, Maritime

Risk Management Services

SpecialEventInsuranceRequest

SpecialEventInsuranceprovidedbyRiskManagementServicesisonlyavailableforeventsoncampus.

Completethisformandturnitin2weeksbeforeyoureventdatetoRiskManagementat

mspotorno@csum.edu|Administration Building|Office 707-654-1076

ContactInformation

EventHolder’sName

EventHolder’

sAddress

PointofContactName

Phonenu

mber

Email

EventInformation

EventTitle/Name

EventLocatio

n

Date

StartTime EndTim

e

Agegroup

Numb

erofguests

Willtherebealcoholicbeverages

served?

Yes No

TypeofEvent(Alsodescribeactivitiesthatwilltakeplaceatthisevent,i.e.Birthdaypartywithbasketballgame):

RevisedFebruary 2016

RMSOfficeuseonly

PersonPreparingQuote

Date

PremiumQuoted DateCertSent DatePaid

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