Vendor Renewal Application
Effective Date
Expiration Date

Administrator - Override Policy Dates

Over $100,000: We will contact you with a customized price quote

Policy Holder Information

Contact & Mailing Information

Business Information

CLAIMS HISTORY

We cannot process a new request for insurance while a potential claim is pending

This form will not process if you continue. Please resolve your issues before attempting to take out a new policy.

If you have questions, you can reach us here: 317-848-9075.

We cannot process a new request for insurance if you are not in compliance.

This form will not process if you continue. Please resolve any issues before attempting to take out a new policy.

If you have questions, you can reach us here: 317-848-9075.

Product Information

Thank you for you interest in this insurance program. Due to the nature of your products we are unable to offer a quote at this time.

This form will not process if you continue.

If you have questions, you can reach us here: 317-848-9075

Total

Payment Information

Please make sure to enter the correct billing address of the cardholder. An incorrect billing address can result in a problem processing your payment information.

Credit Card Billing Address *
Credit Card Billing Address
City
State/Province
Zip/Postal
Credit Card *
Credit Card
Exp Month
Exp Year
CVC/CVV

Renewal Confirmation

The information above is accurate. Please renew my policy with the information above. *

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

Acceptance of Terms and Conditions *
After purchasing this policy, you can add as many additional insureds as needed at no extra cost.