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EVENT CANCELLATION & NON-APPEARANCE APPLICATION BROKER INFORMATION Broker/Agency Name: Contact Person: Phone #: E-Mail: GENERAL APPLICANT INFORMATION Name of Insured: Name of Applicant (if

Form W-9 (Rev. March 2024) Request for Taxpayer Identification Number and Certification Department of the Treasury Internal Revenue Service Go to www.irs.gov/FormW9 for instructions and the

SEPTEMBER 2022 T H E S T A T E O F F R A U D A N D F I N A N C I A L C R I M E I N T H E U. S. T A B L E O F C O N T E N T S Introduction . . . . . . . . . . . . . . .

Our NOWI program can’t be beat. U.S. Risk announces a new program for Non-Operating Working Interest Lease Operators. Specialty Underwriting | Oil & Gas Program Building solid, professional

Specialty Underwriting | Contractors Pollution Liability REV 12.02.2020 Building solid, professional relationships is the foundation of success. U.S. Risk is committed to this concept and

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GENERAL INFORMATION Effective Date: Insured Name: Mailing Address : Property Address (if different to above) UNDERWRITING INFORMATION NFIP Flood Zone_________ 100% Replacement Cost

PRG 142051 (12-22) ©All rights reserved. Page 1 of 2 DEMO DERBY SUPPLEMENTAL APPLICATION Track Name: Event Date: Event Location: Are Activities held according to rules? Please attach

PRG 142052 (12-22) ©All rights reserved. Page 1 of 1 DRAG RACING SUPPLEMENTAL APPLICATION TRACK NAME: Length of Competition Area (from starting line to finish line): 1/8 Mile 1/4 Mile

PRG 142055 (12-22) ©All rights reserved. Page 1 of 1 DRIVING SCHOOL SUPPLEMENTAL APPLICATION 1. Does your “school” have a website? 2. Please describe the school operations in detail (attach

PRG 142057 (12-22) ©All rights reserved. Page 1 of 1 FOREIGN DRIVER QUESTIONNAIRE Named Insured: ______________________________________________________________ Policy Number: _________________

MOTORSPORTS OFF-TRACK AND STORAGE SUPPLEMENTAL Use in conjunction with ACORD Equipment Floater Application Safehold Sports is a division of Innovation Growth Partners Specialty, LLC

SUPPLEMENTAL APPLICATION SWAP MEET If so, do you require the vendors to name you as an additional insured on their insurance? Yes No Please provide a copy of insurance

MOTORSPORTS OFF-TRACK AND STORAGE QUESTIONNAIRE PRG 142071 (12-22) ©All rights reserved. Page 1 of 6 Effective Date of Coverage: I. APPLICANT INFORMATION Full Name of Insured as it is to

March 14,2021 COMMUNICABLE DISEASE EXPOSURE AND INFECTION ASSUMPTION OF RISK, HOLD HARMLESS, RELEASE, WAIVER OF LIABILITY AND INDEMNITY AGREEMENT ________________________________ FILL IN TRACK

Facility Insurance Application Facility Name I Facility Age Contact Person I Title Facility Location Phone I Fax I Email Annual Admissions I Seating I Total Capacity I Total Gross Receipts

HEALTH CLUB FACILITY SUPPLEMENTAL GENERAL LIABILITY APPLICATION (Separate application required for each location) Effective Date: Date of Application: -------------------- ---------------

PROFESSIONAL LIABILITY ■ Defense outside limit option available ■ Personal injury included when related to professional services ■ Contingent BI/PD coverage available ■ Claims Made and

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HEALTH CLUB FACILITY SUPPLEMENTAL GENERAL LIABILITY APPLICATION (Separate application required for each location) Effective Date: Date of Application: -------------------- ---------------