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Campbell Risk Management
WFMA Farmers Market Vendor Application

Thank you for choosing to participate in the WFMA Farmers Market Vendor Liability Insurance Program. Vendors liability insurance will provide you with $1,000,000 of general and product liability per occurrence with a $2,000,000 annual aggregate limit while at any organized venue you participate inThe coverage also extends over the sale of your products through any retail or wholesale distribution channel you choose. The vendor policy is not location specific. You can add and drop locations at any time. You are automatically covered at these locations and the markets are automatically covered as additional insureds without having to be specifically listed on your certificate of insurance. 

The cost of the policy is only $275 for most vendors who have gross annual revenues of $40,000 or less. Rates increase by approximately $5.00 for every $1,000 in gross sales over $40,000. (Gross revenue thresholds and rates per $1000 may vary by location within the state of WI.) Amounts are paid annually and include all taxes, administration and first certificate fees. Once coverage is extended, the amount paid is fully earned and non-refundable. Coverage is provided by an A rated insurance company. By filling out and submitting this application you have read and agree to the terms.

ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AND APPLICATION AGREEMENT
*Form must be completed in its entirety. An incomplete form could result in a delay in processing your request. DEDUCTION AUTHORIZATION AND APPLICATION AGREEMENT TERMS If indicated above I hereby request and authorize Proinsur Inc. dba Campbell Risk Management an agent for the designated Writing Company (hereinafter "the Company") to initiate electronic or other commercially accepted-type debits against the indicated bank account at the bank named above for the payment of premiums and other indicated charges due on the policy applied for. I hereby agree to indemnify and hold the Company harmless from any loss claim or liability of any kind by reason or dishonor of any debit. I understand that the Company may cancel the listed insurance policies for nonpayment of premium as allowed by law. I agree that this Authorization is to remain in full force until revoked by me or the Company in writing and until the Company and the above named bank each have a reasonable opportunity to act on their vocation. I understand that I will be charged a $15 fee for an attempted EFT or returned check that is not honored for insufficient funds. I certify that all applicable federal state and local permitting procedures for the sale of my products are kept up to date and that all food safety requirements are being followed. The submitter is an authorized representative of the applicant and certifies that reasonable inquiry has been made to obtain the answers to all the questions on this application. You are hereby notified that under the Terrorism Risk Insurance Act as amended that you have a right to purchase insurance coverage for losses resulting from acts of terrorism as defined in Section 102(1) of the Act: The term "act of terrorism" means any act that is certified by the Secretary of the Treasury - in concurrence with the Secretary of State and the Attorney General of the United States - to be an act of terrorism to be a violent act or an act that is dangerous to human life property or infrastructure to have resulted in damage within the United States or outside the United States in the case of certain air carriers or vessels or the premises of a United States mission and to have been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion.You should know that where coverage is provided by this policy for losses resulting from certified acts of terrorism such losses may be partially reimbursed by the United States government under a formula established by federal law. However your policy may contain other exclusions which might affect your coverage such as an exclusion for nuclear events. Under the formula the United States government generally reimburses 85% of covered terrorism losses exceeding the statutorily established deductible paid by the insurance company providing the coverage. The premium charged for this coverage is provided below and does not include any charges for the portion of loss that may be covered by the federal government under the act. You should also know that the terrorism risk insurance act as amended contains a $100 billion cap that limits U.S. Government reimbursement as well as insurers' liability for losses resulting from certified acts of terrorism when the amount of such losses in any one calendar year exceeds $100 billion. If the aggregate insured losses for all insurers exceed $100 billion your coverage may be reduced. I hereby decline to purchase terrorism coverage for certified acts of terrorism. I understand that I will have no coverage for losses resulting from certified acts of terrorism. I certify that the answers are true correct and complete to the best of my knowledge. Any person who knowingly and with intent to defraud any insurance company of other person files an application for insurance containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto commits a fraudulent insurance act which is a crime and subjects the person to criminal and civil penalties. By submitting this authorization and application I acknowledge that I have read and agree to the conditions set forth in this agreement and application.
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If you have any questions, please contact Campbell Risk Management, Larry Spilker 800-730-7475 ext 203. Fax 317-848-9093, e-mail, lspilker@campbellrisk.com mailing address, 9595 Whitley Drive #204, Indianapolis, IN, 46240.