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Applicant Info
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Business Info
03
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Certificate Request
04
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Declaration
Total:
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Vendor Application
Thank you for your interest in working with us.
Name
Doing business as (DBA)
Address
Phone
Email
Website
Start my coverage on this date
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DD
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YYYY
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01
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Applicant Info
02
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Business Info
03
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Certificate Request
04
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Declaration
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Vendor Application
Thank you for your interest in working with us.
Vendor Type
Please select
Antique & Collectibles Vendor
Apparel & Accessories
Arts & Craft
Celebrity, Mascot, or Character Appearance
Cookware
Disc Jockey (private event less than 200 attendees)
Face Painting
Food and Drink
Game Trailer or Booth
Gift Wrap Booth
Photo Booth
Photographer or Videographer
Produce or Floral Vendors
Product Demo
Product or Service Display
Retail Cart
Souvenir Sales
Sports & Camping Equipment
Vehicles, Equipment or Hardware Sales on Display
Please select
Event Name
(If you are purchasing a 6 month - Annual policy, please list all events.)
Event Location
Description of Your Exhibit/Goods:
If applicable, will alcohol be served by this vendor?
Yes
No
Will your exhibit or goods involve any use of Fire other than cooking, Fireworks or Firearm Ammunition?
Yes
No
Has any prior coverage been canceled or non-renewed for this customer?
Yes
No
If yes, please describe and provide loss history:
Has this customer had any insurance claims in the last five (5) years?
Yes
No
If yes, please describe and provide details of all claims:
Will your exhibit include mechanical or inflatable amusement devices?
Yes
No
What is the maximum number of days you will spend outside the U.S. for instruction
Note: Coverage applies only if your responsibility to pay damages is determined in a suit brought in the U.S.
Program Cost
(includes premium and a $30 administration fee)
Limits of Liability $1M/$2M
Program Rate 5 consecutive days or less: ($120.60)
Program Rate 6-14 days: ($173.62)
Program Rate 15-30 days: ($258.43)
Program Rate 1-6 months: ($438.66)
Program Rate 6 months - Annual: (Call 888-389-3900)
Note:
PREMIUMS ARE 100% FULLY EARNED AND NON-REFUNDABLE ONCE COVERAGE BEGINS
Price
USD
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01
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Applicant Info
02
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Business Info
03
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Certificate Request
04
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Declaration
Total:
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Vendor Application
Thank you for your interest in working with us.
Once your enrollment form is approved, you will receive a Certificate of Insurance as evidence that coverage is bound.
Complete this section if you require additional certificates listing a facility, property owner or similar third-party as an additional insured on your policy.
Provide a separate request for each additional certificate needed.
Note: Please request all additional insureds needed for this policy term. Additional insureds from the expiring policy term will not be automatically renewed.
When is this certificate needed?
MM
/
DD
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What is the additional insured’s relationship to you?
Owner/manager/lessor of premises (facility or venue)
Sponsor
Co-promoter
Owner/manager/lessor of premises (facility or venue)
NOTE: The certificate holder will automatically be an Additional Insured for an Owner/manager/lessor, Sponsor or Co-Promoter relationship
Certificate holder/additional insured name
Mailing address:
Does the certificate holder/additional insured require any special wording or endorsements?
Yes
No
If yes, check all that apply:
CG2026 (No additional premium)
Primary Non-Contributory ($50 additional premium)
Waiver of subrogation ($75 additional premium)
Non-owned/Hired Auto ($175 additional premium)
NOTE: Please attach a copy of the insurance requirements/instructions you’ve received.
Delete all uploads
Choose files or drag here
The most common delay in certificate processing is caused by providing partial or incorrect name and/or instructions. Please check your request carefully before submitting.
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01
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Applicant Info
02
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Business Info
03
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Certificate Request
04
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Declaration
Total:
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Vendor Application
Thank you for your interest in working with us.
EXCLUSIONS
Excluded Activities:
Horse Vaulting/Jumping, Trick/Stunt Riding, Equine Racing Exposures, Leasing of Horses, Inflatable Amusement Devices, Carnival Rides, Knockerball/Bubble Soccer, Bungee Devices, Fireworks Sales and Display, Mechanical Bucking Devices: including Multi Ride Attachments, Permanent & Mobile Rock Wall Structures, Rock Climbing, Security Services Other Than Contracted Law Enforcement Officers, Trampolines, Zip Lines, Tackle Football, Surfing, Zippy Pets, White Water Rafting, Water Skiing, Trackless Trains, Participants of Aerial Activities
Ineligible Vendor Types:
Body piercing or tattooing, Catering Companies, Christmas tree retail lots, Corn or Hay maze, Disc-Jockeys for events over 200 attendees, E-commerce selling, Entertainment and Film Industry Vendors, Food Truck Vendors, Haunted attractions, Hot wax impressions, Live animals, Live Bands, Marijuana and other cannabis products and/or paraphernalia, Massage, Medical testing, Motor sports activities, Nutritional/health supplements, On-site installation/service/repair of products, On-site equipment rental, Oxygen/aromatherapy, Storefront operations, Time share sales, Tobacco products, Vehicles in motion, Watercraft exhibits on water, Weapon sales, Weight-loss plans or products, Wholesale business
PLEASE NOTE:
Catering Companies, Christmas tree retail lots, Corn or Hay mazes, Disc-Jockeys for events with over 200 attendees, Haunted attractions, Live Bands, Food Truck Vendors, Entertainment & Film Industry Vendors are not eligible under this program, however, you can apply to receive a quotation.
Warranty and Disclosure Statement:
I understand that the insurance company, in determining whether to provide insurance coverage, will rely on the information contained in this form and all other information being submitted. I hereby warrant, represent and confirm that, to the best of my knowledge, all information provided is complete, true and correct. I am aware that the insurance company expects accurate reporting for my premium calculation. I understand that my book and records may be examined or audited by the insurance company at any time during the coverage period and up to three years thereafter. Intentional misrepresentation or misreporting may jeopardize coverage. We reserve the right to decline/void any ineligible coverage. I further acknowledge that, I have reviewed all information provided with this enrollment form and understand the exclusions which apply, as well as the activities and operations for which coverage is not provided.
Print Name and Title
Date
MM
/
DD
/
YYYY
Signature of Proposed Assured
Clear
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