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APPLICATION FOR WEATHER INSURANCE: No coverage will be provided until a signed application indicating desired terms is completed and payment in full is received and approved by good weather in advance of the event. Weather Insurance cannot be cancelled.

In the following states, the client must also receive this Fraud Warning with the application: AR, CO DC, FL, KY, ME, NJ, NM, NY, OH, OK, VA.

AGENT / BROKER INFORMATION:

AGENCY NAME:
CONTACT:
ADDRESS:
CITY:
STATE:
ZIP:
TEL:
FAX:
E-MAIL:
  LICENSE IN APPLICANT'S STATE:
YES    NO 		   
  E&O COVERAGE:
YES    NO
   

 

CLIENT INFORMATION:

    
INSURED:
(NAME AS IT SHOULD APPEAR ON CONTRACT)
CONTACT:
(SPACE)
ADDRESS:
 
CITY:
STATE:
ZIP:
TEL:

TYPE OF EVENT:
    
     
LOCATION:
 
CITY:
STATE:
ZIP:
    

DATES OF COVERAGE:		    
FROM:
       TO: 
HOURS OF COVERAGE FOR EACH DATE:    
FROM:
       TO: 

LIMIT OF INSURANCE FOR EACH DATE:		    
 
POLICY LIMIT:
   
PREMIUM:

SPECIFIC PERIL:		    
     

WEATHER MONITORING (select one):		    
  Closest National Weather Station:   
  Independent Weather Observer    ON-SITE    OFF-SITE
OBSERVER NAME:
OBSERVER TEL:
 

 

 
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