Marine Corps League, Etal

Date of Request *

MM

DD

YYYY

Applicant Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Person (Billing) *

First Name

Last Name

Contact Person (Billing) Phone Number *

(###)

###

####

Contact Person (Loss Control) *

First Name

Last Name

Contact Person (Loss Control) Phone Number *

(###)

###

####

Select One

For Profit

Non Profit

Individual

Partnership

Association

Other

Has The Applicant Had Any Claims Filed Against It In The Last Four (4) Years? *

Yes

No

Will Invited / Professional Athletes Be Participating? *

Yes

No

Does the Applicant Carry Accident & Health Coverage? *

Yes

No

Is Alcohol Being Served? *

Yes

No

Address of Venue *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is the Event Limited to Venue Grounds?

Yes

No

Are Certified Lifeguards on Duty?

Yes

No

Are They CPR Trained?

Yes

No

Are Certificates Received by the Applicant?

Yes

No

Is the Applicant Required to Provide Certificates of Insurance to Any Other Entity?

Yes

No

Name *

MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN,CEO, OR EXECUTIVE DIRECTOR

First Name

Last Name

Date Signed *

MM

DD

YYYY

Authorized Representative Declaration *

The above signed warrants that he or she is authorized and has the authority to complete and execute this Application, including the Warranty Statement, on behalf of the Applicant and its respective Directors, Officers, or other insured individuals.

Producer

First Name

Last Name

Producer Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Electronic Signature Agreement *

By clicking the "I Accept" checkbox, you are signing this Questionnaire electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Questionnaire.

I Accept