Bret Dixon Insurance - Your All-In-One Insurance Solution

The greatest compliment to our business is a referral. If you know someone who is looking for insurance, who may benefit from our services or would be interested in a free coverage, please forward their contact info or have them contact our office directly.

Special Event Survey

This is just an application, coverage is not in effect. Further underwriting information may be necessary.

Applicant
Email Address
Mailing Address
City, State ZIP	,
Telephone
Do you use a D/B/A (Doing Business As)?	Yes No
If yes, what is it?
Applicant is:
Event location address
City, State ZIP	,
Type of Event
Describe all festivities and entertainment
Is a liquor license or permit required?	Yes No
Limit of insurance desired
List name and address of any additional interests
Starting date and time of event	/ at
Ending date and time of event	/ at
Estimated number of attendees
Quantity of beer
Quantity of wine or Champaign
Quantity of hard liquor
Will someone other than applicant be serving?	Yes No Who?

Please note, you may not bind, nor alter coverage without speaking to an authorized company representative.

Corporate Headquarters: 403 S. Prairie St. | P.O. Box 205 | Bethalto, IL 62010

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