Contact Name *

First Name

Last Name

Phone *

(###)

###

####

Business Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you want insurance to cover you: *

Annually (All Events)

Individual Event

Coverage Start Date *

MM

DD

YYYY

Coverage End Date *

MM

DD

YYYY

Has your previous coverage ever been Cancelled of Refused? *

Yes

No

Have you had any claims in the past 4 years? *

Yes

No

Will alcohol be served by this vendor? *

YES

NO

Will your operations involve any use of Fire other than cooking, Fireworks or Firearm Ammunition? *

YES

NO

Will your operations include mechanical or inflatable amusement devices? *

YES

NO

Are any of the event operations to be insured located outside of the United States? *

YES

NO

Have you or your company ever been involved in any legal dispute relating to the operations or products of your company or business? *

YES

NO

Do you operate any of the following: Body piercing or tattooing, Catering Companies, Christmas tree retail lots, Corn or Hay maze, Disc-Jockeys for events over 200 attendees, DJ Companies with more than 1 Employee, E-commerce selling, Entertainment and Film Industry Vendors, Fire Dancing, Fire Eating, Food Trucks, Haunted attractions, Heavy Machinery, Hot wax impressions, Live Edge Weapon Performers, Live animals, Live Bands with more than 1 individual, 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, Timeshare sales, Tobacco products, Vehicles in motion, Watercraft exhibits on water, Weapon Throwing, Weapon sales, Weight-loss plans or products, Wholesale business? *

YES

NO

The undersigned being authorized by and acting on behalf of the applicant and all persons or concerns seeking insurance, has read and understands this proposal and declares all statements set for herein are true, complete, and accurate. The undersigned further declares and represents that any occurrence or event taking place prior to the inception of the policy applied for which may render inaccurate, untrue, or incomplete any statement made herein will immediately be reported in writing to the insurer. The undersigned acknowledges and agrees that the submission and the insurer’s receipt of such report prior to the inception of the policy applied for is a condition precedent to coverage. It is understood and agreed that the completion of this application shall not be binding either to the Proposed Insured or to the Company until accepted by the Company or Companies. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly provides false information in an application for insurance may be guilty of a crime and may be subject to civil fines and criminal penalties. I certify that the above information is true and coverage is not applicable until accepted. *

I Agree