Vendor/Exhibitor Liability Application

*Required
Company Information			Paper Version
Company Name
First Name*
Last Name*
Address*
City*
State*
Zip*
Daytime Telephone Number*
Mobile Telephone Number
Fax Number
Your Email Address*
Your Website Address
Years Experience*
Who, if anyone, referred you to us?*
For Insurance Agents & Brokers Only: Brokers Name
General Information
Products Sold/Exhibited *
Include Products Liability?
Size of Selling Area (in feet)
Desired Effective Date of Policy
Desired Expiration Date of Policy
Who was your previous insurance company*
Premium paid: $*
List all previous claims (Last 5 years)*
Information on 1st Upcoming Event
Event Name or Description
Event Date(s)
Name of Venue/Location
Venue Mailing Address
City
State
Zip
Telephone Number
Fax Number
Contact Person (First & Last Name)
Contact Person Email Address
Location Additional Insured Wording (Found in your rental agreement)
Notes/Special Instructions
Volunteers & Spectator Accident Medical Option The Liability Policy will usually only provide Medical Payments coverage if you are at fault for an accident involving a spectator or volunteer. For a quote on "no fault" medical reimbursement ("goodwill insurance"), choose this option.
Number of Volunteers Daily
Total Number of Volunteers (All Days Combined)
Do you want Spectators included in the coverage?
Application Warranty & Instructions 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 OF 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.
Name of person acknowledging Warranty*
Date of acknowledgment*
For Insurance Agents & Brokers Only
Your Company Name
First Name
Last Name
Address
City
State
Zip
Daytime Telephone Number
Mobile Telephone Number
Fax Number
Your Email Address