Delta Sigma Theta Insurance Application

Form - Delta Sigma Theta Insurance Application

Registration Information

Name *

Officer Title *

Phone *

Please enter your 10 digit numerical phone number without hyphens or special characters.

Email *

Chapter Name *

Chapter Address *

Chapter Fax Number

Today's Date *

Event Information

Name of the Event *

Start Date *

End Date *

Beginning Time of Event * :

End Time of Event * :

Event Details *

Location of Event *

Chapter Facility

Off Campus Rented Facility (Hotel, Bar, Restaurant, etc.)

On Campus Facility

Off Campus Venue

Member(s) Residence

Other

Venue Information

Venue Name *

Venue Contact *

Venue Contact Phone *

Please enter your 10 digit numerical phone number without hyphens or special characters.

Venue Contact Email *

Venue Address *

Is the Event Co-Sponsored *

Co-Sponsoring Organization *

Co-Sponsoring Organization's Contact Name *

Cell Phone *

Please enter your 10 digit numerical phone number without hyphens or special characters.

Email *

Purpose of Event *

Art & Music

Athletics (e.g. walks, runs, etc.)

Boat Rentals

Cultural

Demonstration

Formal

Fundraising

Group Business

Learning

Parade

Parent Event

Party

Philanthropy

Service

Social

Spirituality

Voter Registration

General Member Intake (ie. non Rush, NIP/DPR, Sisterhood Event)

Membership Intake RUSH

Membership Intake NIP/DPR

Membership Intake Sisterhood Event

Other

Please Upload Membership Intake Activity Form *

Uploading Files. Please Wait.

Drop a file here or click to upload Choose File

Maximum upload size: 2.1MB

Determining the Cost of Event

*Events exceeding 1000 participants will require a complete Underwriting Submission. Please contact the DST Team at DSTTeam@holmesmurphy.com

What type of event are you hosting? *

Option 1

Option 2

Option 1: Regular Chapter Meeting, Installation of Officers, Members only event, Regular Schedule Delta Youth Initiative, Membership Intake – non-RUSH, DPR/NIP, or Sisterhood Event
Option 2: All others

Limit of Insurance: *

$1M per occurrence /2M aggregate

$2M per occurrence/3M aggregate

For this option, there is NO fee. Please complete the form to request any additional insured certificates.

Will there be alcohol at the event? *

Yes

Number of attendees (including members, non-financial members, non-members, guest, etc *

Limit of Insurance: *

$1M/2M

$2M/3M

*CERTIFICATE HOLDER CERTIFICATE – A Certificate Holder Certificate will include the third party of venue on the Certificate of Insurance showing the insurance coverage is in force as outlined in a written contract. This certificate does not extend coverage to the third party.
*ADDITIONAL INSURED CERTICATE – An Additional Insured Certificate extends liability insurance coverage beyond the named insured to include other individuals or groups. An additional insured endorsement protects the additional insured under the named insurer's policy allowing them to file a claim if sued.

Is a Certificate Holder Certificate, or an additional Insured Certificate required for the event? *

Yes

If a Certificate Holder Certificate or Additional Insured Certificate is not required by the third-party vendor or facility, nothing further is needed.

IF YES:
CERTIFICATE HOLDER CERTIFICATE – A Certificate Holder Certificate will include the third party of venue on the Certificate of Insurance showing the insurance coverage is in force as outlined in a written contract. This certificate does not extend coverage to the third party.

Is a Certificate Holder Certificate required for the event? *

Yes

IF NO:
If a Certificate Holder Certificate is not required by the third-party vendor or facility, nothing further is needed.

Is an additional Insured Certificate required for the event? *

Yes

If an Additional Insured Certificate is not required by the third-party vendor or facility, nothing further is needed.

Legal Entity Name for Organization *

Mailing Address to Appear on Certificate *

Contract must be submitted (attach below) *

Drop a file here or click to upload Choose File

Maximum upload size: 2.1MB

Number of Attendees (no alcohol) *

0-250 ($100)

251-500 ($200)

501-750 ($300)

751-1000 ($400)

Number of Attendees (alcohol) *

0-250 ($200)

251-500 ($300)

501-750 ($400)

751-1000 ($500)

Number of Attendees (no alcohol) *

0-250 ($200)

251-500 ($400)

501-750 ($600)

751-1000 ($800)

Number of Attendees (alcohol) *

0-250 ($400)

251-500 ($600)

501-750 ($800)

751-1000 ($1000)

Number of Attendees (no alcohol) *

0-250 ($150)

251-500 ($300)

501-750 ($450)

751-1000 ($600)

Number of Attendees (alcohol) *

0-250 ($300)

251-500 ($450)

501-750 ($600)

751-1000 ($750)

Number of Attendees (no alcohol) *

0-250 ($300)

251-500 ($600)

501-750 ($900)

751-1000 ($1200)

Number of Attendees (alcohol) *

0-250 ($600)

251-500 ($900)

501-750 ($1200)

751-1000 ($1500)

*Participate Accident Coverage is required for athletic events (i.e. 5k runs/walks, kickball or softball events, etc.) This coverage will complement the health insurance program of non-member participant for injuries as a result of an accident at the event. This will be an additional fee that will be billed separately by Holmes Murphy.

Is Participant Accident Coverage required for the event? *

Yes

Number of non-member participants *

Chapter Type? *

graduate chapter

undergraduate chapter

Number of total participants *

Delta Sigma Theta Event Insurance Application

Registration Information

Event Information

Venue Information

Uploading Files. Please Wait.

Determining the Cost of Event

Payment must be received prior to the approval of your application and the issuance of any certificates needed.