Additional Insured Request Form
for Mark Nizer Performance

NOTE: Please complete this form to have you added to Mark's liability insurance for your performance.
Technical Requirements and Contract Riders are available online here.

This form is for events buyers only. If you have hired Mark Nizer for an event, fill out the form below and we'll add you as an additional insured on his liability insurance. This is NOT REQUIRED for a performance, but is placed here as a convienence for clients.
Contact Person (required):
Venue (required):
Name of additional insured
(please type EXACTLY as it is to appear on the certificate: (required):
Show Date (required): *Check Date
Street Address (required):
City (required):
State (required):
Zip Code (required):
Phone Number (required):
Email (required):
Web Address:
Comments or Special Requests:

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Mark Nizer™
and/or Active Media Group™
Contact Site Administrator: Active Media Group.