Market Application - Campbell Risk Management

Requested Policy Effective Date *

Policy End Date *

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 *

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 market or business to be insured (include DBA if applicable) *

Email *

Phone *

Fax

Website/URL

Type of Entity (Corp Non-Profit Sole proprietor) *

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 *

Do you require your vendors to have product and general liability insurance naming the market as an additional insured? *

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