A- Onsite Consumption Application

Mailing Address:
Mailing Address:
City
State/Province
Zip/Postal
Proposed Effective Date (include any set up and tear down dates):
12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
Applicant is:

Limits Of Liability and Deductible Requested:

General Aggregate (other than Products/Completed Operations)
$
Products and Completed Operations Aggregate
$
Personal and Advertising Injury (any one person or organization)
$
Each Occurrence
$
Damage To Premises Rented To You (any one premise)
$
Medical Expense (any one person)
$
Other Coverages, Restrictions, and/or Endorsements:
$
Deductible
$