Mud Run Application Form
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5MUD RUN APPLICATION
Cossio Insurance Agency
864-688-0121
Fax: 864-603-2348
P.O. Box 5987, Greenville, SC 29606
DIRECTIONS:
DIRECTIONS:
DIRECTIONS:
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
POLICY RECOMMENDATIONS
(Please check any you are interested in)
General Liability
Accident Medical
Earthquake
Inland Marine
Workers Compensation
Commercial Auto
EPLI
Flood
Hired & Non-Owned Auto
Cyber Liability
Umbrella
Abuse / Molestation
Section 1: CONTACT INFORMATION
How did you hear about us?
...
Contact Name:
DOB:
FEIN/SS#
Corporate Name:
Business Name:
Do you wish to receive quote by:
Fax
Email
Mail
Fax:
Phone:
Email:
Address of Applicant:
City:
State:
Zip:
Section 2: EVENT INFORMATION
Dates of Event
Time(s)
Name of Event
Location of Event
City:
State:
Zip:
Name of Facility:
Does the Facility Carry Liability Insurance?
No
Limits:
Yes
Description of Event
Are you Responsible for Parking?
No
If Yes, Square Footage of Parking Area
Yes
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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Revised 6/16/17
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Parent category: Business