Named Insured

Applicant's name

Street address

City

State

Zip

Phone

Fax

E-mail address

Additional Insured 1

Name and Address

Additional Insured 2

Name and Address

Additional Insured 3

Name and Address

EVENT INFORMATION

Products/Services being sold at the Event(s)

Dates of event

Desired coverage dates

* Include setup and teardown dates

Estimated number of events to be attended annually

FOR ANNUAL COVERAGE ONLY: Number of events to be attended annually. “Event” can be considered as a festival, conference, sporting event, private party etc. An estimated range for number of events to be attended is acceptable for quoting.

Estimated Annual Gross Receipts

FOR ANNUAL COVERAGE ONLY

PAST INFORMATION

Has this event been held before?

YES

Number of years event has been previously held

Actual total attendance for previous year's event

Have you had General Liability coverage as a Vendor before?

YES

Have you ever had a General Liability claim as a Vendor?

YES

Has any insurance carrier cancelled or refused coverage?

YES

LIABILITY INFORMATION

LIMITS OF LIABILITY REQUESTED

Please note that our standard limits of liability are $1,000,000 occurrence and $2,000,000 aggregate. Most venues/cities/locations require this minimal amount of coverage. We do not offer policies less than $1,000,000 in occurence limit.

Excess General Liability

Please note we have the ability to raise the limits of liability over $1,000,000 occurrence—some venues/cities/locations require this. Selecting Excess General Liability is not advised unless a venue/city/location is requesting higher limits as this will increase the total premium. If you have questions about this, please contact our office.

Require Non-Owned/Hired Automobile coverage?

YES

Require Abuse/Molestation coverage?

YES

AFFIRMATION AND SIGNATURE

Fraud statement

Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

I ACKNOWLEDGE

Warranty statement

I hereby warrant and confirm that the above information, to the best of my knowledge, is true and correct, and further certify that I have read all of the questions and answers on this application. I understand this application is a requirement for coverage, a part of the contract and evidence of my acceptance of this insurance, and any falsification or misrepresentation will be deemed a breach of contract, voiding all insurance coverage. It is understood and agreed that the completion of this application shall not be binding either to the proposed insured or the company until accepted by the company or companies in writing.

I AFFIRM

Title

Name of Applicant

Signature of Applicant

Date

BROKER INFORMATION

Name of Authorized Agent or Broker

Name of Agency

Agency Mailing Address

E-mail

Phone

Fax

VENDOR & FOOD TRUCKS

Vendor

TYPES OF “VENDOR” CLASSIFICATIONS: