Fillable Winco Fireworks International, LLC Extension of Liability Insurance

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Winco Fireworks International, LLC Extension of Liability Insurance

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Winco Fireworks International, LLC
Extension of Liability Insurance
Fact Sheet
Certificates must be paid for before issuance.
If an order is not received by June 1
st
for 4
th
of July Season and/or November 1
st
of Christmas/New Year Season, the certificate will be
cancelled.
Product liability is automatically included on all Winco Fireworks International, LLC product purchases. Certificates reflecting proof of
product liability are available upon written request.
The certificate is proof of premise insurance. The certificate does not drive the coverage, the policy does. The certificate merely shows the
limits of liability and the carrier.
As an “additional insured” on Winco Fireworks International, LLC is extending liability to the customer for the sale of Winco Fireworks
International, LLC product only. We are extending coverage to the customer as an additional insured for property damage or bodily injury
to a third party (in other words, the customer’s clients who purchase Winco Fireworks International, LLC product only).
The customer is responsible for all of their own property coverage such as stock, tables, tents, building, etc.
The customer is responsible for paying the $2,500.00 deductible should a claim be filed for any injury or accident from the insured location
noted on the certificate.
The cost on the request form and noted above, can be for all selling seasons noted on the request form if conducted at the same location and
within the same calendar year.
If a customer is open year round, they need to purchase their own liability insurance.
Certificates of Insurance cannot be issued for customer display shows and/or shoot offs.
Certificates of Insurance cannot be issued unless a complete and signed request form is received by Winco Fireworks International, LLC
and an order is placed.
Corrections or cancellations to an issued Certificates of Insurance must be received in writing via new form or email. All corrections or
cancellations should be sent to Shelly Hastings at shelly@wincofireworks.com
If you carry product other than Winco Fireworks International, LLC product, you need to secure separate coverage from each vendor.
As soon as you become aware of an incident, it is a requirement that you notify Winco Fireworks Management immediately. Every effort
should be made to report an incident within 30 days of the occurrence.
Please allow 24 hours for processing once your request is received.
WINCO FIREWORKS INTERNATIONAL, LLC
EXTENSION OF LIABILITY INSURANCE
CERTIFICATE REQUEST
Please Print or Type (
All information must be completed
):
Customer Account # (if current customer):
Customer Company Name Requesting:
Do you require an insurance extension for Liability? ☒Yes No
1 Million - $375.00 Administrative Fee for Certificate processing (Valid for all selling seasons at same location in same calendar year if noted below)
5 Million - $675.00 Administrative Fee for Certificate processing (Valid for all selling seasons at same location in same calendar year if noted below)
Certificate Holder (if different from Company Requesting):
Address:
City: State: Zip:
Phone Number: (____) Fax: (____
)
E-mail Address:
Dates stand is open to public for 4
th
of July Selling Season: to
Dates stand is open to public for Christmas/New Year’s Selling Season: to
Dates of additional selling season: to
Location (must reflect the physical address):
Address:
City: State: Zip:
Stand Operator’s Name:
Landowner’s Name:
Additional Insured’s:
All individuals/entities listed on the certificate of insurance will be deemed an additional insured per this contract. I also understand
should any injury or accident result in a claim from the above insured location, I will be responsible for the $2,500.00 deductible.
Signature: Date:
TO BEGIN PROCESSING, FAX OR EMAIL COMPLETED FORM TO:
ATTN: Shelly Hastings Fax #: (816) 697-2219 or Email: shelly@wincofireworks.com
*This certificate is proof of insurance. This certificate does not drive the coverage, the policy does. The certificate merely shows the limits of liability and the carrier. As an “additional insured” on Winco Fireworks International, LLC, we are extending liability to you for the
sale of Winco product only. We are extending coverage to you as an additional insured for property damage or bodily injury to a third party (in other words, your clients who buy Winco fireworks only).
*Certificates of Insurance cannot be issued unless a complete and signed request form is received by Winco Fireworks International, LLC.
*Corrections or cancellations to issued Certificates of Insurance must be received in writing via new form or email.
*Please allow 24 hours for processing.
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Winco Fireworks International, LLC Extension of Liability Insurance

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Completed 22 December 2020

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