Haunted House Liability Application Page 3
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5Haunted House Liability Application
Cossio Insurance Agency
864-688-0121
Fax: 864-603-2348
P.O. Box 5987, Greenville, SC 29606
Section 2: GENERAL INFORMATION (Continued)
Please describe any losses over $5,000.00
30. Name, Address and Relationship of all Additional Insureds to be Added to the Policy:
ADDITIONAL INSURED #1
Name:
Relationship:
Address:
ADDITIONAL INSURED #2
Name:
Relationship:
Address:
ADDITIONAL INSURED #2
Name:
Relationship:
Address:
Please Attached All Hold Harmless Agreements, Brochures and a Diagram of Location(s) to be Used.
Signature of Applicant:
Printed Name of Applicant:
Date:
Email completed application to or Fax to: 864-688-0138
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
Umbrella
Abuse / Molestation
Cyber Liability
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