MUD RUN APPLICATION
Cossio Insurance Agency
P.O. Box 5987, Greenville, SC 29606
1. Fill in the application by ﬁlling in the blue ﬁelds on all pages.
2. Please ﬁll in all the ﬁelds with the correct information.
1. Complete the enrollment form (all pages) in full by filling in the blue fields.
1. Complete the application (all pages) in full by filling in the blue fields.
3. Mail the completed quote request form to:
3. Email the application to or Fax to 864-603-2348
(Please check any you are interested in)
Hired & Non-Owned Auto
Abuse / Molestation
Section 1: CONTACT INFORMATION
How did you hear about us?
Do you wish to receive quote by:
Address of Applicant:
Section 2: EVENT INFORMATION
Dates of Event
Name of Event
Location of Event
Name of Facility:
Does the Facility Carry Liability Insurance?
Description of Event
Are you Responsible for Parking?
If Yes, Square Footage of Parking Area
What is the Number of Tickets Sold to Date?
Number of Tickets Printed?
Participants per day?
Spectators per day?
What is the Price of Admission?
What is the Estimated Gross Receipts?
Total # of employees:
What is the Estimated Total Payroll?
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