Market Application Market Application If you are human, leave this field blank. Have you had this type of policy with Campbell Risk Management in the last 12 months? * Yes No Requested Policy Effective Date * Policy End Date * Administrators - Override Policy Dates Estimated gross annual revenue from space rental * $0 to $50,000 $50,001 to $100,000 Over $100,000: We will contact you with a customized price quote Choose your limits of insurance * $1,000,000 per occurrence / $2,000,000 aggregate limit $2,000,000 per occurrence / $4,000,000 aggregate limit Policy Holder Information Contact & Mailing Information Contact First Name * Contact Last name * Street Address * Address Line2: City: * State * Alabama Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Physical address of market: (include city state & zip) If you have more than one market location please list address for each market location. Business Information Name of the market or business that you own or run (include DBA if applicable) * Email Address: * Phone * Fax Website/URL Type of Entity (Corp Non-Profit Sole proprietor) * Corporate LLC Partnership or Joint Venture Individual/Sole Proprieter Year started in this business * Number of Employees * Are there other operations or special events outside the scope of regular farmers market/craft fair type activities? * Yes No If Yes please explain event activities including date(s) location and estimated number of attendees: Market History & Information Number of liability insurance claims in past 3 yrs at farmers markets * If any claims, please explain Is this an open air farmers market? * Yes No If not, please describe age, size, and construction of premises Average number of vendors * It is mandatory that markets require their vendors to maintain a commercial general liability policy that includes product liability. Policy limit should be a minimum of 1 million per occurrence with a 2 million aggregate limit. Each vendor policy needs to list the market as an additional insured or contain a blanket additional insured endorsement and provide the market with a certificate of insurance confirming coverage. I agree to upload all vendor certificates to Campbell Risk Management for verification of proper coverage at least 10 days prior to the markets opening date. A link will be emailed to you for this purpose. * Yes No We cannot process a new request for insurance while a potential claim is pending. It is mandatory that market require all their vendor to have insurance and to list the market as an additional insured. This form will not process if you continue. If you have questions, you can reach us at 317-848-9075. Do vendors sell guns ammunition alcohol automobiles ATV's watercraft children's furniture or children's toy's or offer amusement rides? * Yes No Please give details on guns ammunition, Do vendors sell guns ammunition alcohol automobiles ATV's watercraft children's furniture or children's toy's or offer amusement rides sold What is your average daily attendance? * When is the market open? * Does the market lend, lease, or rent equipment to others? * Yes No If so please describe equipment and annual revenue Terms & Conditions By filling out the preceding form, any farmers market or vendor is eligible to become a member of the FM&V RPG, managed by Campbell Risk Management. RISK PURCHASING GROUP NOTICE This FM & V Purchasing Group Policy is protected by the insurance insolvency guaranty fund in the state of Illinois. You may also have rights under your state of domicile's insurance solvency guaranty fund. However, the insurer or Risk Purchasing Group may not be subject to all the insurance laws and rules of your state of domicile. IMPORTANT NOTICE REGARDING RISK PURCHASING GROUPS Disclosure Pursuant to Federal Law Regarding Purchasing Groups [15 U.S.C. SEC. 3901, et seq] FM & V Purchasing Group is a "Risk Purchasing Group", as defined under Federal law, formed to purchase liability insurance on a group basis for its Members to cover the similar or related liability exposure(s) to which the Members of the Risk Purchasing Group are exposed by virtue of their related, similar, or common businesses or services. Members do not share limits and each member is provided with its own policy and/or evidence of insurance. Read Terms & Conditions Terms & Conditions * By checking this box I accept the Terms & Conditions Totals Order Total Purchase This Insurance After purchasing this policy, you can add as many additional insureds as needed at no extra cost.
