Vendor Application – Insurevents

Vendor Liability Application

"*" indicates required fields

Policyholder Information

Please, do not type in ALL CAPS anywhere on this form.

Your Company Name

Your Full Name*

Address*

Street Address City State ZIP Code

Primary Phone Number (Preferably Mobile)*

DO NOT place a 1 in front of your telephone number.

Can this phone accept texts?*

Yes

Email (If you are an insurance broker, use your email & not your clients)*

Enter Email Confirm Email

Website

How many years of experience do you have?*

Who referred you to us?

Are you a Non-Profit Corporation?

Yes

Are you an insurance agent/broker applying for a quote on behalf of your client?*

Yes

For Insurance Agents & Brokers Only

Your Insurance Agency Name

Agents First Name

Agents Last Name

Address

Mailing Address City State / Province / Region ZIP / Postal Code Country

Telephone

DO NOT place a 1 in front of your telephone number.

Remember to enter your email address on the previous screen in lieu of your client's email.

General Information

Products Sold/Exhibited*

Size of selling area (in feet)*

Estimated attendance at your booth*

Start Date of Your Policy (First Set-Up Date)*

Your policy cannot start any sooner than the next business day after application submission.

Which Policy Term Would You Like Us To Quote?*

Last Date You Need Coverage*

Your policy will start on the date you indicated above and will end on this date:

Estimated Total Gross Sales During This Policy Term*

Are you involved in any of the following: Body piercing or tattooing; Fireworks sales & displays; Hot wax impressions; Live animals; Massage; Medical testing; Motor sports activities; Nutritional/health supplements; On-site installation/service/repair of products; On-site equipment rental; Oxygen; Aromatherapy; Time share sales; Tobacco products; Vehicles in motion; Watercraft exhibits on water; Weapon sales; Weight-loss plans or products; Medical marijuana and/or paraphernalia; Catering Companies; Christmas tree lots; Corn or Hay mazes; Disc-Jockeys for events with over 200 attendees; Haunted attractions; Live Bands; Mechanical or inflatable amusement devices; Food Truck.*

Yes

Explain your Yes answers*

Your previous Insurance company*

Premium Paid

List any previous claims*

Information on your 1st upcoming event

Name of Event or Description*

Event Dates*

Name of Location or Promoter*

Their Contact's First & Last name*

Contact's Email

Contact's Telephone

Address*

Mailing Address City State / Province / Region ZIP / Postal Code Country

Venue's/Promoter's additional insured wording (found in your rental agreement)

Does the contract require a Primary & Noncontributory endorsement?*

Higher rates apply if you need it.

Yes

Does the contract require a Waiver of Subrogation endorsement?*

Higher rates apply if you need it.

Yes

Upload a copy of your vendor contract with the Promoter/Location

Acceptable file types: pdf, jpg, gif, png, doc, docx, xls, xlsx. Maximum File Size: 128MB.

Drop files here or

Accepted file types: pdf, jpg, gif, png, doc, docx, xls, xlsx, Max. file size: 256 MB.

Any additional information we need to know?

Options That Can Be Added To your Policy

Additional premium will apply.

Would you like a quote for the sale or serving of alcohol? (Liquor Liability)*

Recommended if you hold a liquor license, or are receiving ANY monies, including door receipts, from anyone (including caterers, bars, etc.) based on alcohol sales.

Yes

Are you directly selling, serving, or sharing income from the sale of alcohol?*

Yes

Estimated total liquor sales?*

Name on Liquor License*

How will you prevent serving minors & the intoxicated?*

Describe the training & experience of persons serving alcohol*

Average age of attendees?*

Average cost of a drink?*

Number of patrons you will serve?*

Would you like a quote for Rented/Borrowed Auto Liability?*

Yes

Number of vehicles you will rent or borrow?*

Your cost to rent the vehicles?*

Are all drivers at least 25 years old?*

Any vehicles seat more than 12 persons?*

What will the vehicles be used for?*

Would you like a quote for Rented &/or Owned Equipment?*

Yes

Description of all equipment*

Describe protection / security at principal location*

Total Value of Rented Equipment/Sets/Props/Contents?*

Total value of Owned equipment/Sets/Props/Contents?*

Date rented equipment is being picked up*

Date the last of the equipment is returned*

Would you like a quote for Workers' Compensation?*

Yes

Number of workers*

Payroll,*

Describe workers' duties*

Your Federal I.D. Number*

Name & Title of an owner or corporate officer*

You and all other owners, officers and directors of the company will be excluded from coverage.

Social Security Number*

Would you like a quote for Volunteer / Staff / Performer Accident Medical?*

This coverage is not a substitution for workers' compensation insurance. See above.

Yes

Number of Daily volunteers?*

Number of Daily staff?*

Number of Daily Performers?*

Describe what duties the volunteers will have*

This field is for validation purposes and should be left unchanged.

Resources

Client Services

Resources

Client Services

Vendor Liability Application

Policyholder Information

For Insurance Agents & Brokers Only

General Information

Information on your 1st upcoming event

Options That Can Be Added To your Policy

Support

Client Services

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