11. Equipment—Does the Applicant rent, furnish or install any of the following equipment?
Amusement Devices Barricades Bleachers Dance Floors
Folding Chairs/Tables Sound Equipment Stages/Staging Tents
Portable Restrooms Space Heaters
12. Does Applicant have Workers’ Compensation coverage in force? ............................................................. Yes No
Does Applicant lease employees? .............................................................................................................. Yes No
13. Does Applicant have Professional Liability coverage in force? .................................................................. Yes No
14. Does Applicant have Liquor Liability coverage? ......................................................................................... Yes No
15. Does the Applicant have a Web site? ......................................................................................................... Yes No
If yes, provide Web site address:
16. Attach:
(a) Any descriptive advertising literature;
(b) Copy of Applicant's standard contract with clients;
(c) Copies of all agreements in which the Applicant has assumed liability; and
(d) Separate detailed narrative descriptions as required.
Contact Person:
Phone Number:
FRAUD WARNING:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance 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 subjects such
person to criminal and civil penalties.
FRAUD WARNING (APPLICABLE IN TENNESSEE AND WASHINGTON):
It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance 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 also be
subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an owner, partner or executive officer)
PRODUCER’S SIGNATURE: DATE:
GLS-APP-63s (11-06) Page 4 of 4
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