Vendor Liability Purchase Step 1 of 4 25% Policyholder InformationYour Company NameInsurance Brokers- DO NOT put your name here. You will be asked for that information on the next screen. Your Full Name*Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary Phone Number (Preferably Mobile)*Can this phone accept texts?*YesNoSecondary Phone NumberCan this phone accept texts?*YesNoEmail (If you are an insurance broker, use your email & not your clients)* Enter Email Confirm Email obsolete 8-20-19 WebsiteHow many years of experience do you have?*Are you a Non-Profit Corporation?YesNoWho referred you to us?Are you an insurance agent/broker applying for a quote on behalf of your client?*YesNoFor Insurance Agents & Brokers OnlyYour Insurance Agency NameRemember to enter YOUR email address above, NOT your client's email. Otherwise they will receive automatic notifications and our quote instead of you.Agents First NameAgents Last NameAddress Mailing Address City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands TelephoneFaxRemember to enter your email address on the previous screen in lieu of your client's email. General InformationProducts 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. Date Format: MM slash DD slash YYYY Which Policy Term are you purchasing?*5 Days / $175 Premium14 Days / $250 Premium1 Month / $300 Premium6 Months / $425 PremiumAnnual / $500 PremiumAre 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.*YesNoExplain your Yes answer*Your previous Insurance company*Premium PaidList any previous claims* Information on your 1st upcoming eventName of Event or Description*Event Dates*Name of Location or Promoter*Their Contact's First & Last name*Contact's Email Their TelephoneFaxAddress* Mailing Address City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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.YesNoDoes the contract require a Waiver of Subrogation endorsement?*Higher rates apply if you need it.YesNoUpload a copy of your vendor contract with the Promoter/LocationAcceptable 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. Any additional information we need to know? Options That Can Be Added To your PolicyAdditional 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.YesNoAre you directly selling, serving, or sharing income from the sale of alcohol?*YesNoEstimated 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?*YesNoNumber 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?*YesNoDescription 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 Format: MM slash DD slash YYYY Date the last of the equipment is returned* Date Format: MM slash DD slash YYYY Would you like a quote for Workers' Compensation?*YesNoNumber 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. YesNoNumber of Daily volunteers?*Number of Daily staff?*Number of Daily Performers?*Describe what duties the volunteers will have*PhoneThis field is for validation purposes and should be left unchanged.