VENDORS — FRANCIS L. DEAN & ASSOCIATES, LLC

VENDORS INSURANCE PARTNERS SIGN UP

I want to streamline the Vendor/Exhibitor/Concessionaire event insurance process for you and your clients. Please complete 1 form (below) for each event you are hosting. I will customize an online insurance program for your event(s). You will receive certificates of insurance immediately upon each purchase, via email.

EVENT NAME

Description of Event (Type of event):

Location Address of event:

First Date of Event:

Desired START date of insurance coverage:

Desired date of coverage should include the set up/take down dates required. These dates will determine the policy term, and therefore the premium.

Last Day of Event:

Desired END date of insurance coverage:

Desired date of coverage should include the set up/take down dates required. These dates will determine the policy term, and therefore the premium.

Contact Name

First Name

Last Name

Phone

(###)

###

####

ALL EMAIL ADDRESSES TO RECEIVE COPIES OF INSURANCE CERTIFICATES.

These addresses will receive copies of insurance certificates at moment of successful purchase. (Event Organizers, Venues, Municipalities, etc.)

ADDITIONAL INSUREDS (Provide names and full addresses):

These are the event organizers, venues, municipalities who wish to be added as additional insured on each vendor insurance policy that is purchased through the program.

PLEASE PROVIDE ANY SPECIAL LIMITS, POLICY LANGUAGE OR ENDORSEMENTS REQUIRED OF YOUR VENDORS:

How did you hear about me and my programs?