Vendor / Exhibitor Application

Client Information
Organization.   Contact
Insured Name:*   Name:*
Trade Name*:   Phone:*
Address:(No PO Boxes)*   Fax:
Suite, Floor, ect..:   Phone (Cell):
City*   Email:*
State Zipcode* Website:
Form of Business: Individual - Partnership - LLC - Trust - Other, If Other:
Number of years you have been in business as a vendor:
Provide a list or description of the products you sell, handle, or display in your operations*:


Operations to be Insured
Which of the following best describes the area in which you conduct the operations to be insured:.
Trailer - If patrons enter the trailer, give the dimensions:
Food Trailer - Number of trailers utilized at one time:
Game Trailer - Number of games utilized at one time:
Tent - Give the dimensions:
Booth - What is the height of your booth/display? Dimensions:
Push Cart - Number of carts utilized at one time:
Out Door Area - Give the dimensions:
Other - Please describe and provide dimensions:

Event Information (Single Event Coverage)
Event Start Date:
Event End Date:
Hours of Event:
Event Name:
Venue Name:
Address:
Address Additional:
City:
State, Zipcode


Event Information (Six Month or Annual Coverage) If you are applying for this coverage you will need to answer the following:
New or Renewal:
Desired effective date:
Desired end date:
Note: Coverage will not be made effective prior to the date that the enrollment form and
payment are received by CSI.
Number of shows you will attend during the coverage period:
Do you attend more than one show simultaneously?
Name of Event:
Date(s) of Event:
Venue Name:
Address:
City:
State, Zipcode


Additional Insureds
Additional Insured 1
Name:   Phone:
Address:   Fax:
City:   Email:
State, Zipcode:      
Relationship: Artist - Owner - Sponsor - Government




Applicant
How did you hear about CSI Insurance?
Preferred contact method
 Email - Phone - Fax
Applicant Signature:*
Applicant Title:*

FRAUD STATEMENT: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON, FILES AN APPLICATION FOR INSURANCE COMPANY OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SHALL BE SUBJECT TO CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. WARRANTY STATEMENT: I HEARBY 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 ON 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 CMPANY UNTIL ACCEPTED BY THE COMPANY OR THE COMPANIES IN WRITING.