Frazier Insurance Agency > Prize Indemnity

General Information

Named Insured:
Applicant's name:
Street address:
City:
State:
Zip:
Phone:
Fax:
E-mail address:

Event Information

Type of Event(s) / Promotion(s) / Competition(s) - Please provide full details including contest rules: *
Dates of Event(s): -
Have you any past experience in staging event(s) of this kind? If so, please explain:

Affirmation and Signature

Declaration:

To the best of my knowledge and belief the information provided in connection with this application is true and I have not withheld any material facts. I understand that non-disclosure or misrepresentation of a material fact will entitle the company to void coverage. (A material fact is one likely to influence acceptance or assessment of this application by the companyl if you are in doubt as to what constitutes a material fact, consult your agent.) I understand that signing this application does not bind me to purchase the coverage but agree that should a contract be issued, this form and the statements made hereon shall be the basis for such contract.

Title:
Name of Applicant:
Signature of Applicant:
Date:

Broker Information

Name of authorized Agent or Broker:
Name of Agency
Agency Mailing Address:
E-mail:
Phone:
Fax:

Prize Indemnity Application

Please note: