Sports Application

IF YOU ARE A VENDOR OR EXHIBITOR PLEASE DO NOT FILL THIS APPLICATION OUT
CLICK THIS LINK FOR VENDOR / EXHIBITOR COVERAGE
Client Information
Name Insured/Organization:*
Address:*
City:*
State, Zipcode:*
Contact Email:*
Contact Phone:*
Location Information  
Location Name:*
Location Address:*

Location City:*
Location State, Zipcode:*
 
Estimated number of attendance, participants, or members:
Number of Spectators:
Number of Participants:
Number Of Events:
Desired Effective Date:*
Desired Termination Date:*


Event Details
Complete description of event/activity:
Describe security protection:
Who contracts security?:
Facility Applicant
Hold Harmless?
Yes No
Emergency evacuation plan in place:
Yes No
Qualified medical personnel in attendance:
Yes No
Ambulanceservice in attendance:
Yes No
Will concessions will be sold?
Yes No
Will alcoholoc beverages be served:
Yes No
Will alcoholic beverages be sold:
Yes No
If yes, estimated reciepts
Will concessionaries provide you with certificates evidencing products liability with your organization names as Additional Insured
Yes No No Concessionaries


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.