COVER-PRO
SM
APPLICATION
TICKET BROKER SUPPLEMENT
1. Full name of the Applicant Firm:
2. Is the Applicant licensed in their state of operatio
n?
Yes No
3. Has the Applicant’s license ever been revoked or suspended?
Yes No If yes, provide an expla
nation.
4. Does the Applicant maintain a permanent business address (othe
r than a residence) with p
ublished hours and
accessible to customers? Yes No
5. What percentage of the Applicant’s gross ann
ual revenue comes from the following activities?
% In-pe
rson sales
% Telephone sales
% Internet sales
% Other: (specify)
% Other: (specify)
% Other: (specify)
100
% TOTAL MUST EQUAL 10
0%
6. Does the Applicant have a published refund, sche
duling, and ca
ncellation policy? Yes No
(Please attach a copy)
7. How does
the Applicant acquire the ti
ckets which they re-sell?
8. Does
the Applicant ever sell tickets at the event venue? Yes
No
9. What is the
Applicant’s d
isclosure policy with regard to ticket limitation / rest
rictions?
10. Is the Applicant a member of the National Association of Ticket Broke
rs or US Ticket Broker
Association?
Yes No
I understand that the information submitted herein becomes a part of my Philadelphia Insurance
Companie
s Cover-Pro
sm
application and is subject to the same conditions as stated on the application.
Name (Please Print) Title (Must be Principal, Partner or Officer
)
__________________________________________
Signature Date
PI-PLSP-TBSUPP 08/
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