Public Liability Insurance Request Form

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DAA Group Name*
Contact name*
Contact phone number*
Contact email*
Date of Event

Day
Month
Year
Event Time/Duration*
Event to be conducted by*
Event venue/address*
Reason for holding this event*
How will you advise the public where any money raised will be spent*
Why do you feel this event is relevant/important to your Group*
Number of group members to be involved*
Number of spectators expected*
Will members of other DAA Groups be involved in this event*
Please provide any other supporting information/material you think may be relevant to your request
Signature
Name
First Last
Date Signed
MM slash DD slash YYYY
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