Event Quotation Form

QUOTATION FOR EVENT MEDICAL COVER

This form will allow us to provide you with a quotation for Event Medical Cover. Please ensure you fill out this form with as much detail and accuracy as possible.

Providing false information will result in an automatic denial of services for your event.

Organiser Details

These should be the details of the person filling out this quotation form.

Name*

Organisation/Company Name*

Best Email Address*

Telephone Number*

Event Details

Please allow 30 minutes before the start time for setup and 30 minutes at the end for pack down.

Name of Event*

Related Website*

Start Date of Event*

End Date of Event*

Medical Team Onsite Time*

Public Expected Arrival Time*

Public Expected Offsite Time*

Medical Team Stand Down Time*

Address of Proposed Event*

What3Words Location

Detailed Explanation of Event*

Safety & Documentation

Do you have a Risk Assessment in place?*

Yes No I need help doing this

Upload Risk Assessment (if Yes)

Event Plan Available?*

Upload Event Plan

Insurance Documents* Failure to provide insurance documents may result in cancellation of cover.

Site Logistics

Site Contact Details (Name, Role, Phone)*

Free Parking for Staff?*

Access to Refreshments?*

Access to Toilets?*

Access to Electricity?*

Will our team have a private sheltered area?*

Treatment Area Description / Setup Location*

Other Medical Organisations Involved?

Cover Requirements

Will the General Public be on site?*

Yes No

Max People Onsite (inc. staff)*

Crowd Make-up*

Activities taking place (Tick all that apply):

Street Carnival Fireworks Climbing/Abseiling Motorised Sports Licensed Bar Contact Sports

Other/None - Please specify:

Nearest A&E Department (Name & Address)*

Previous Event History / Expected Levels of Care*

What level of medical cover do you require?*

Safety Advisory Group (SAG)

Are SAG aware?*

CRG Rep at SAG Meeting?*

SAG Meeting Details (Date, Time, Location)

Personnel & Equipment Required

Conveying Ambulance Additional Treatment Point Off-road 4x4 Stretcher Paramedic Doctor Specialist Personnel

Specialist Personnel/Equipment Details:

Any other useful information?

Billing Details*

Who is responsible for payment should you accept the quotation?

Billing Address*

Billing Phone Number*

Invoice Email Address*

How did you hear about us?