ALL QUESTIONS MUST BE ANSWERED IN FULL AND …
|[pic] |FLEA MARKET SUPPLEMENT |
| |(Complete in addition to ACORD Application) |
|Proposed First Named Insured & Other Named Insured(s): |
| |
|Location Address Street City County State ZIP Code |
| |
|BUSINESS INFORMATION |
|1. |Part occupied by Named Insured: Entire Portion ( %) Other (Lessor’s Risk Only) |
|2. |Date business established: |
|3. |Describe all business operations conducted: |
| | |
|4. |List all premises you own, rent, or control (attach schedule if necessary): |
| |Location |Age |Construction |
| | | | |
| | | | |
| | | | |
| | |Yes |No |
|5. |Do you have a parking lot? | | |
| |If yes, state area: | | |
| |If you charge for parking lot use, indicate gross receipts from this operation: $ | | |
| |Type of surface: Gravel Black Top Concrete | | |
| |Is area checked regularly for potholes and uneven surfaces? | | |
|6. |Facility is: Indoor Outdoor Drive-In Theater | | |
| |Other (describe): | | |
|7. |Number of vendor spaces: | | |
| |Annual gross receipts from space rental: $ | | |
|8. |Is there an admission charge? | | |
| |Annual gross receipts from admissions: $ | | |
|9. |Average daily attendance: | | |
|10. |Days per week facility is open: | | |
|11. |Do you provide display booths? | | |
| |If yes, describe: | | |
|12. |Are materials fire resistive? | | |
|13. |Does aisle space meet local fire department regulations? | | |
|14. |Are fire extinguishers kept on premises? | | |
| |Frequency serviced: | | |
|15. |Do you utilize a lease agreement? | | |
| |If yes, obtain a copy for the file. | | |
|16. |Are you provided with a certificate of insurance and additional insured endorsement from vendors? | | |
|17. |Do you have any golf carts? | | |
| |If yes, how many: | | |
|18. |Total number of employees: | | |
|19. |Is liquor allowed on premises? | | |
| | |Yes |No |
|20. |Do you sponsor any special events or promotions? | | |
| |If yes, describe: | | |
|21. |Do any vendors offer amusement rides? | | |
| |If yes, describe: | | |
|22. |Do you use any traffic control? | | |
| |If yes, describe: | | |
|23. |Do you store petroleum products in underground tanks, LPG, flammable liquids, ammunition or explosives on the premises? | | |
| |If yes, indicate type and quantity stored: | | |
|24. |Do you subcontract work? | | |
| |If yes, indicate type: | | |
| |Are Certificates of Insurance required from all subcontractors? | | |
|25. |Do you lend, lease or rent any equipment to others? If yes, indicate: | | |
| |Type of equipment: | | |
| |Gross receipts: $ | | |
|26. |Has emergency evacuation plan been prepared? | | |
|27. |Are emergency facilities readily available? | | |
| |If yes, describe: | | |
|IMPORTANT NOTICE |
|DECLARATION |
|I DECLARE THAT THE STATEMENTS MADE IN THIS PPLICATION ARE COMPLETE AND TRUE. |
|As part of our underwriting procedures, a routine inquiry may be made to obtain applicable information concerning character, general reputation, and credit |
|history. Upon your written request, additional information as to the nature and scope of the report, if one is made, will be provided. |
|SIGNATURES |
|Applicant Signature |Title |Date |
|Producer Signature |Date |
|Producer Name and Address |
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