10. Debris Fence:
Fence post material (wood, concrete, metal):
Number of feet between fence posts:
Height above racing surface:
Type/gauge of fence wire:
Does debris fence protect all Spectator Areas? .......................................................................................... Yes No
11. Seating:
Grandstand or bleacher seating capacity:
Grandstand/bleacher construction material:
Age:
Are spectators permitted to sit in: Their autos to watch the race? .......................................................... Yes No
The infield? ........................................................................................ Yes No
The pit area? ..................................................................................... Yes No
Are there grandstands in the pit area? ........................................................................................................ Yes No
Are the grandstands in the pit area protected by a barrier?......................................................................... Yes No
12. Are there any playground/amusement rides on the premises? ................................................................... Yes No
13. Is there a medical or first aid facility on the premises? ................................................................................ Yes No
14. Does the applicant have a Web site? .......................................................................................................... Yes No
If Yes, provide the Web site address:
15. 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-62s (11-06) Page 2 of 2
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