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PROGRAM DESCRIPTION
This program has been designed for U.S.-based Car Clubs. We offer affordable general liability protection for your club’s car shows, meetings, rallies, and social functions. While participating in your covered
activities, the general liability coverage extends to your officers, members, and volunteers. Excess liability limits are available. The program automatically includes Products Liability (food or drink) and $1 million Commercial General Liability. Legal Liability to Participants (LLP), which applies to motorized events and protects your club if it is found to be legally liable for a participant’s injuries, is included. (LLP coverage is effective only upon receipt of each participant’s signature on a Release and Waiver of Liability Agreement provided by K&K Insurance Group, Inc.) For your competitive events, such as autocrosses, gymkhanas or rallies, we can also provide general liability for officials, car owners, drivers, pit crews, sponsors, advertisers, and any person or organization operating, managing, sanctioning, sponsoring or providing the premises for your covered program.
Coverage is provided by a carrier rated A+ (Superior) by A.M. Best Company.
INELIGIBLE OPERATIONS
•
Wheel to Wheel Racing•
Boating Risks•
Hill Climbs•
DriftingELIGIBLE OPERATIONS
•
Independent Clubs•
Organizations operating the premises for covered programs•
Autocross•
Business Meetings•
Caravans•
Concours•
Gymkhanas•
Parade Participants•
Poker Runs•
Rallies•
Slaloms•
Social Functions•
Tours•
Other one car at-a-time events•
Motorcycle Clubs (refer to company for underwriting and pricing)•
Off Road Events (refer to company)MOTORSPORTS INDEPENDENT CLUB EVENT LIABILITY
Insurance Program and Enrollment Form
WAYS TO ENROLL FOR COVERAGE
FAX 1-260-459-5102 MAIL Regular: K&K Insurance Motorsports/ICEL P.O. Box 2338 Fort Wayne, IN 46801-2338 E-MAIL [email protected] Submit this enrollment form, with payment, to K&K.
Overnight: K&K Insurance Motorsports/ICEL 1712 Magnavox Way Fort Wayne, IN 46804 QUESTIONS Call 1-800-348-1839 This brochure is for illustrative purposes only and is not
COVERAGES AND LIMITS
* Contact K&K at 1-800-348-1839 if higher limits are needed *
Coverage provided under this program includes:
Commercial General Liability – coverage which protects the insured against liability claims for bodily injury and property
damage arising out of premises, operations, products and completed operations and personal and advertising injury.
Legal Liability to Participants – coverage which offers protection against bodily injury liability claims brought by persons
participating in “covered programs”.
The following represent only some of the exclusions contained in this policy.
EXCLUSIONS
• Abuse, molestation, harassment or sexual conduct
• All operations listed as ineligible • Amusement devices (eg: rides, slides, inflatables, bungees, climbing walls or devices, dunk tanks) • Asbestos • Employment-related practices • Fireworks • Fungi or bacteria • Lead
• Nuclear energy liability • Pollution
Coverages - Annual Coverage for Business Meetings and
Social Functions. Car Clubs
Commercial General Liability
Each Occurrence
Limits
$ 1,000,000 General Aggregate (Other than Products-completed Operations) None Products-completed Operations Aggregate (food and drinks) $ 1,000,000
Personal and Advertising Injury $ 1,000,000
Damage to Premises Rented to You $ 300,000
Legal Liability to Participants $ 1,000,000
Expense Reimbursement for Competition Vehicles Damage Claims
(90% co-payment) $ 100,000
Official Vehicle Property Damage ($1,000 deductible) $ 1,000,000
Errors and Omissions $ 100,000
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FREQUENTLY ASKED QUESTIONS
1. What coverages are available?
Our basic plan offers general liability protection, with limits of $1 million. (Excess limits are available by request). Legal Liability to Participants protection, with coverage limits matching the General Liability, and Products Liability Protection (Food and Drink), are also included.
2. When is the insurance effective?
Your insurance will be effective when we’ve received your completed plan application and premium payment and approved the risk. You should receive your coverage documents and all necessary supplies to administer your insurance program within 30 days of the effective date of your coverage.
3. Do I need to notify you of club events?
You should provide a schedule of events to K&K, but you do not need to notify us prior to each of your non-competitive events, such as business meetings and social functions. However, competitive events, such as autocrosses, gymkhanas or rallies, and other public events operated by your club, such as parade participation and car shows are not included in the basic membership premium and require that you arrange for coverage at least two weeks before the event. Contact us for an event premium quotation and supplemental application.
ICEL CRITERIA
1. 16 year old driver requirement and 16 year old
passenger requirements. (Applies only as respects Non-Spectator Events as noted on page 5. Refer to K&K if any deviation.)
2. K&K approved Waiver and Release must be signed by all persons entering a restricted area.
3. Because Sports Car Club events are considered private events, members of the general public must be denied access to the event premises.
Independent Club Event Liability (ICEL)
Insurance Application
Name of Insured (as will appear on policy): _______________________________________________________________ Doing Business As: __________________________________________________________________________________ Mailing Address: ____________________________________________________________________________________
City:______________________________________ State:______ Zip:_____________ Phone: ( ______) ______________ Street Address: _____________________________________________________________________________________
City:______________________________________ State:______ Zip:_____________ Phone: ( ______) ______________ Contact Person: _____________________________________________________________________________________
Person is:
m
Ownerm
Promoterm
Agentm
Other: ______________________________________________Day Phone: (______)__________________ Cell Phone: (______)___________________Fax: (______) _______________ E-mail Address: _____________________________________________________________________________________
Web Site Address: ___________________________________________________________________________________ Name of Agency/Brokerage (if applicable): ________________________________________________________________
Contact Person: _____________________________________________________________________________________ Mailing Address: ____________________________________________________________________________________
City:______________________________________ State:______ Zip:_____________ Phone: ( ______) ______________
Fax:(______)______________________ E-mail address:_________________________ Tax ID #: ___________________ Nature of operations/description of event: _________________________________________________________________
__________________________________________________________________________________________________
Insured is:
m
Corporationm
Partnershipm
Joint Venturem
Limited Liability Corporationm
Other (explain): ________________________________________________________________________In what state is the organization headquartered/chartered?___________ Policy period requested: From_______________________________ To ________________________________________
UNDERWRITING INFORMATION
Has this type of insurance ever been:
m
Cancelledm
Declinedm
Non-renewedIf so, please explain. (Not applicable in Missouri) ___________________________________________________________ Does this organization engage in any other business operations under the name of the insured
as it will appear on the policy?
m
Yesm
NoIf yes, please explain. ________________________________________________________________________________
__________________________________________________________________________________________________ As respects your operation(s), do you enter into any contracts?
m
Yesm
NoIf yes, what contracts do you enter into? __________________________________________________________________ __________________________________________________________________________________________________ Please submit an Independent Club Event Liability (ICEL) Event Coverage form for each event along with this application. Also, please review, acknowledge compliance of, then sign and return the Autocross event minimum insurance qualifications for any Autocross events.
1620 12/11 Page 5 of 11
Car Clubs:
Per member rate subject to a minimum earned premium of $500:
m
0-100 Members: $6.20 per member x _____ Number of Club Members = Membership Premium $_____m
101-500 Members: $4.40 per member x _____ Number of Club Members = Membership Premium $_____m
501 or More Members: $3.05 per member x _____ Number of Club Members = Membership Premium $_____ANNUAL MEMBERSHIP
1. Club membership premium ($500 minimum): $__________ 2. Total premium for all events: $__________ 3. Risk Purchasing Group membership fee: $__________ Total premium due (add lines 1 through 3): $__________
EVENT COVERAGE
Event coverage premium from Independent Club Event (ICEL) coverage form(s):
Event #1 premium $_________ Event #3 premium $_________ Event #5 premium $_________ Event #2 premium $_________ Event #4 premium $_________ Event #6 premium $_________
TOTAL PREMIUM
Coverage available for the following club activities and events. Additional premiums apply.
Refer to the attached Independent Club Event (ICEL) Event Coverage Form for applicable
premiums
Car Club Non-Speed Activities:
Class I Auctions Car Washes Guided Tours Public* Breakfasts/Dinners Public* Dances/Shows Public* Picnics Public* Receptions/Seminars Car Shows/Concours
Non-Spectator Events:
Autocross, Gymkhana, Slalom, Solo II Solo I (except Hillclimbs)
Time/Speed/Distance (TSD) Rallies
Additional event types must be referred to K&K Insurance Group, Inc. for Underwriting, Approval, and Rates.
*Public means non-members of the club (not including immediate family of members). Class II
Parade Participants Poker Runs/Toy Runs
Rallies (autos only, no motorcycles)
IMPORTANT NOTICE: An ICEL EVENT INSURANCE COVERAGE must be submitted for each event, prior to the
event, in order to validate insurance coverage. Failure to comply will result in NO INSURANCE coverage for your competitive event.
IF A CERTIFICATE OF INSURANCE IS NEEDED, PLEASE SUBMIT THIS ORDER TWO (2) WEEKS PRIOR TO THE EVENT TO INSURE PROPER MAIL TIME.
1. Name of Insured Club: __________________________________________________________________________
Address: _________________________________________________________________________________________ City:_________________________________________________________ State:_______ Zip: ____________________ 2. Event Date: _______________________________________________________________________________________ 3. Event Location (name of site): _________________________________________________________________________ Address: _________________________________________________________________________________________ City:_________________________________________________________ State:_______ Zip: ____________________ Class I, 0-50 Miles, Attendance 1-250: _____$154 Per Day
Class I, 0-50 Miles, Attendance 251-500: _____$190 Per Day Class I, 51-300 Miles, Attendance 1-250: _____$177 Per Day Class I, 51-300 Miles, Attendance 251-500: _____$219 Per Day Class II, 0-50 Miles, Attendance 1-250: _____$190 Per Day Class II, 51-300 Miles, Attendance 1-250: _____$219 Per Day Autocross, Gymkhana, Slalom, or Solo II: _____$200 Per Day Solo I: _____$475 Per Day TSD Rally: _____$120 Per Day Any certificates required for additional insureds? mYes mNo
If yes, what is their relationship to the club? mManager or Lessor or Premises (i.e.: landowner) mSponsor
Additional Insured Information:
Independent Club Event Liability (ICEL)
Event Coverage Form
Name: __________________________________________ Address: ________________________________________ City:____________________ State:______ Zip: _________ Name and address of premises rented/leased to the insured if applicable:
________________________________________________ ________________________________________________
Name: __________________________________________ Address: ________________________________________ City:____________________ State:______ Zip: _________ Name and address of premises rented/leased to the insured if applicable:
________________________________________________ ________________________________________________
Waiver and Release Requirement: Each event participant MUST sign the K&K Waiver and Release of Liability and Indemnity
Agreement. The appropriate signed waiver must be forwarded to K&K upon request only, and is a condition of Participant Legal Liability coverage. A supply of these forms was mailed to the club insurance representative when the “ICEL” policy was issued. Should you require more forms, please check below and indicate the quantity needed for your remaining events of the year. Please send _______ Waiver and Release forms.
Name of person completing this order: _____________________________________________________________________ Address: ____________________________________________________________________________________________ City:_________________________________________________________ State:_______ Zip: _______________________ Daytime phone: (_____)___________________________ Fax: (_____) __________________________________________
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GENERAL
FRAUD ST
ATEMENT
Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim 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 [NY: substantial] civil penalties. (Not applicable in CO, DC, FL, HI, KS, MA, MN, NE, OH, OK, OR, VT or WA; in LA, ME, TN, and VA, insurance benefits may also be denied)
APPLICABLE IN COLORADO It is unlawful to
knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement of award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
APPLICABLE IN THE DISTRICT OF COLUMBIA
WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant.
APPLICABLE IN FLORIDA Any person who
knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
APPLICABLE IN HAWAII For your protection, Hawaii
law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.
APPLICABLE IN KANSAS Any person who, knowingly
and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.
APPLICABLE IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT Any person who knowingly
and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties.
APPLICABLE IN MINNESOTA Any person who files
a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
APPLICABLE IN OHIO Any person who, with intent
to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deception statement is guilty of insurance fraud.
APPLICABLE IN OKLAHOMA WARNING: Any person
who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
APPLICABLE IN WASHINGTON It is a crime to
knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include
The following exclusions are contained in the commercial general liability coverage provided by this program. Abuse, molestation, harassment or sexual conduct; Aircraft/hot air balloon; Airport; Amusement devices (the ownership, operation, maintenance or use of: any mechanical or non-mechanical ride, slide, or water slide, any inflatable recreational device, any bungee operation or equipment, any vertical device or equipment used for climbing-either permanently affixed or temporarily erected, or dunk tank. Amusement devices do not include any video or computer games or any device that is specifically designated for the training or instruction of the activity for which you are enrolled.); Animals (injury or death to, or injury, death or property damage caused by any animal owned, rented or hired by you); Asbestos; Boating activities; Commercial general liability standard exclusions (CG0001 12/04 edition); Employment-related practices; Fireworks; Fungi or bacteria; Haunted attractions; Lead; Nuclear energy liability; Performers (injury or death to any performer or entertainer during any activity, event or exhibition including but not limited to any stunt, concert, show or theatrical event. This exclusion does not apply to participants in any activity, event or exhibition that are part of the designated operations for which you are enrolled)
COVERAGE EXCLUSIONS
m
Check: Please make check payable to K&K Insurance Group, Inc. Enclosed is check #__________ for $_________m
Credit Card: If you are making your payment by credit/debit card, please complete the following:
m
VISAm
MASTERCARDm
DISCOVERm
AMERICAN EXPRESSCard number: _________________________________________________________________________________________ Reference number (last 3 digits on back of card): __________________ Expiration date: _________________________ I authorize K&K Insurance Group, Inc. to charge my payment to my credit card in the amount of $_______________ Print name(as on card): ________________________________________________________________________________
Cardholder signature ________________________________________________________________________________
Select Payment Plan: Check one:
m
100% Plan• 100% of the total premium is due to bind coverage
m
Check here if you prefer to be mailed an invoice for any future balances/installments.If paying by credit card, any outstanding balances or installments will be charged to the same card number provided below, unless you have checked the box above.
Making your Payment:
PA
YMENT INFORMA
PLEASE NOTE:
• Your event premium check must be postmarked at least one day prior to the event to which this order pertains to have insurance in effect and valid. We cannot accept competitive event requests by phone.
• If your order form or premium payment is incomplete or in error, we will attempt to phone you to correct the error. Coverage is valid only if the order form is completed correctly and appropriate premium is remitted.
• If your club’s premium payment check is not honored by your bank for any reason, the failure of premium payment will jeopardize your coverage for the event to which the check pertains. After one check has been returned by your bank for non-payment, all subsequent future insurance orders will be accepted only on a certified-check or money-order basis without exception.
• If you need a certificate of insurance, or your policy endorsement prior to the event, mail this application at least two weeks in advance to assure you receive the certificate in time. Faxes and telegrams confirming coverage cannot be guaranteed.
Page 9 of 11 1620 12/11
READ AND SIGN
W
ARRANTY AND DISCLOSURE ST
A
TEMENT
I understand that the insurance company, in determining whether to provide insurance coverage, will rely on the information contained in this form and all other information being submitted. I hereby warrant, represent and confirm that, to the best of my knowledge, all information provided is complete, true and correct.
K&K Insurance Group, Inc. as managing general underwriter for the insurance company, receives compensation from the insurance company in consideration for its performance of insurance services that include, but are not limited to; underwriting, policy/certificate issuance, administration and claims handling. The insurance company compensates K&K, based on a predetermined calculation of thirty-three percent of the total premium.The total may also include an annual RPG membership fee up to ten dollars.
I am aware that the insurance company expects accurate reporting for my premium calculation. I understand that my books and records may be examined or audited by the insurance company at any time during the coverage period and up to three years thereafter. Intentional misrepresentation or misreporting may jeopardize coverage. I further acknowledge that I have reviewed all information provided with this enrollment form and understand the exclusions which apply, as well as the activities and operations for which coverage is not provided.
Applicant signature: _________________________________________ Date: ______________________________ Printed name: ______________________________________________ Title: ____________________________________ If an agent: Check here to acknowledge you are signing on behalf of the named insured. m
K&K INSURANCE GROUP, INC. for the insuring Company, shall be permitted, but not obligated, to inspect the IN-SURED’S property and operation for UNDERWRITING AND/OR LOSS CONTROL PURPOSES at any time. Neither the right to make an UNDERWRITING AND/OR LOSS CONTROL INSPECTION nor the making thereof, nor any report thereof, shall constitute an undertaking, on behalf of or for the benefit of any insured, or others, to forecast any accident or its severity or determine or warrant that such property or operations are safe or healthful, or are in compliance with any engineering standards, rules or regulations. THE ESTABLISHMENT OF UNDERWRITING QUALIFICATIONS AND UNDERWRITING AND/OR LOSS CONTROL INSPECTIONS ARE FOR THE SOLE PURPOSE OF DETERMINING THE INSURABILITY OF CERTAIN PROPERTY AND OPERATIONS, underwriting, and seeking to reduce claims against insur-ance and are not for the benefit of any insured or third party. The Insured is solely responsible for the safety of its prop-erty and operations and shall not rely upon any Underwriting and/or Loss Control Inspections or activities to determine the safety of its property or operations and shall not diminish or forego its own safety practices and procedures.
I. EVENT DESCRIPTION
An autocross or Solo II event is a COMPETITIVE EVENT, driving skill contest conducted on courses that emphasize car handling and agility rather than speed or power. The course generally consists of STRAIGHT sections and connecting TURNS or corners, as marked by pylons, generally resembling a miniature road course.
II. EVENT SITES
A. The event is held on a flat surface.
B. RESTRICTED AREAS; must include, at a minimum, the course surface, the area within the circumference of the course, and all other areas within 100 feet of the outside of the course, and the PIT AREA.
C. VIEWING AREAS: Must be designated
explicitly. Must be located beyond the 100 foot RESTRICTED AREA. The boundary between the Viewing Area and the RESTRICTED AREA will be established with at least rope and banner; a fence of some kind is strongly recommended. SPECTATORS are restricted to the Viewing Areas. D. PERMANENT, REAL, FIXED PROPERTY (buildings, trees, light stanchions, similar physical obstructions): May not be closer than 25 feet to the course in STRAIGHTS and/or inside of TURNS, not closer than 75 feet on the outside of the TURNS.
E. PARTICIPANTS are not covered by participant accident insurance unless specifically purchased for that event.
III. EVENT MANAGEMENT
A. Basic rules and standards for conduct of events must be drawn up before an event is run and be available to all drivers.
B. An event chief official must be appointed to supervise the running of the event.
C. Event Safety Official(s) are strongly
recommended. Their sole responsibility should be to monitor the safety of the event.
Autocross Event Minimum
Insurance Qualifications
One safety official should be on-duty at all times. D. All PARTICIPANTS must sign the current K&K waiver form. PARTICIPANTS under the age of majority in the state in which the event is run (or under the age of 18 or which ever is greater) must have a current K&K “Minor Release and Waiver of Liability and Indemnity Agreement” signed by his/her parent(s). Other waiver forms may not be used.
E. All drivers must have a valid driver’s license. Any license or permit which requires another licensed driver in the AUTOMOBILE is not acceptable. Minor drivers must be able to show that they have permission to operate the AUTOMOBILE in the event.
F. All drivers must wear a D.O.T. approved helmet, and must use seat lap belts.
G. Participants are permitted to ride as passengers in the AUTOMOBILE during training sessions and driving schools. Participants are permitted to ride as passengers during the competition run only with the approval of the event chief official. All passengers must meet the requirements of section D & E; Must be in an AUTOMOBILE which has passed technical inspection; Must wear seat belt and approved helmet; Must have signed a waiver. The passenger must be either a student riding with an instructor or an instructor riding with a student during a drivers’ school.
H. FIRE EXTINGUISHERS: There must be at least two 10 BC rated dry chemical fire extinguishers on site and in proper working condition.
IV. COURSE REQUIREMENTS
A. When laying out a course, the size of the AUTOMOBILES competing should be taken into consideration. The following guidelines
are minimum qualifications for insurability. 1. Speeds on STRAIGHT stretches should not exceed 70 m.p.h. for the fastest class of
SPECTATORS and property. Speeds at turns should not normally exceed 45 m.p.h.
2. The course should contain no holes, loose gravel, gratings, oily spots or dips in the course.
V. COMPETING AUTOMOBILES
A. All AUTOMOBILES shall be subject to a strict inspection by qualified technical inspectors. B. Driver/passenger restraints: Seat lap belts are required in all AUTOMOBILES. Installation of the shoulder belts or harnesses is strongly
recommended in AUTOMOBILES with fixed tops or roll bars. Two-strap shoulder harnesses shall not be worn in open automobiles, which are not equipped with roll bars.
C. Roll bars: Roll bars are strongly recommended in all automobiles. Roll bars are REQUIRED in all purpose-built competition cars and any other open cockpit AUTOMOBILES using racing (non-D.O.T. approved) tires.
VI. DEFINITIONS
“AUTOMOBILE” means a “Sports Car” or any self- propelled four wheel land motor vehicle, including vehicles entered in NON-SPEED EVENTS, but does not include mobile equipment. “COMPETITIVE EVENT” means supervised events such as
gymkhanas, time/speed/distance rallies, autocrosses, slaloms, field trials, time trials and similar non-racing one-car-at-a-time events.
“COMPETITION VEHICLE” means any self-propelled
vehicle, land motor vehicle or “watercraft” on the “premises” for the specific purpose of competing or performing in a “covered program”.
“PARTICIPANT” means any person that you grant
permission to enter the “restricted area” but only if: A. The person has clearly defined duties directly allotted to them as respects a “covered program”; and B. The person is within the “restricted area”.
“PIT AREA” means the area used to register the
PARTICIPANTS and prepare the AUTOMOBILES for the event.
“RESTRICTED AREAS” means any area requiring
special authorization, credentials or permission to enter and to which admission by the general public is restricted or prohibited including but not limited to the PIT AREAS, course surface, the area within the circumference of the course and all other areas within 100 feet of the outside of the course.
“SPECTATOR” means any person who is not a
PARTICIPANT nor a member of the general public unassociated with the club.
“STRAIGHT” means a section of the course at least
50 feet in length in which the AUTOMOBILE does not substantially change direction.
“TURN” is any section of the course which is not
STRAIGHT.
I understand that the insurance company in determining whether to provide a quotation for insurance coverage will rely on the information contained in the application and all other information being submitted. I hereby warrant, represent and confirm that, to the best of my knowledge, all information provided is complete, true and correct.
___________________________________________ ___________________________________________ Applicant’s Signature Producer’s Signature (if applicable)
___________________________________________ ___________________________________________ Applicant’s Name (print) Producer’s Name (print)
___________________________________________ ___________________________________________ Date (MM/DD/YY) Date (MM/DD/YY)
