Haunted House Liability Application Page 4
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5SIGNATURE PAGE
Cossio Insurance Agency
864-688-0121
Fax: 864-603-2348
P.O. Box 5987, Greenville, SC 29606
Section 3: Cyber Liability
1. Do you process payment cards?
Yes
No
2. Estimated annual number of payment card transactions
S
ection 4: Warranty
(Applies to all parts of this application and attachments submitted)
It is hereby understood and agreed that if insurance is issued by virtue of completing this application and
any applicable supplemental applications, the Insurance is only issued on the reliance on the applicant’s
warranty of answers to the questions above and on any such supplemental applications. If, at the time a
certificate/policy is issued and ANY OF THE ABOVE WARRANTIES IS IN ANY RESPECT
INCORRECT, INCLUDING CLAIMS OR GROSS RECEIPTS, THE COVERAGE AFFORDED UNDER
THE CERTIFICATE/POLICY shall, without notice to the applicant, immediately and automatically cease,
& the certificate/policy shall BECOME NULL AND VOID. Warranties will survive a certificate/policy
if issued.
Section 5 : Signature
Print Name of Applicant
Title:
Signature of Applicant (Mandatory)
Date:
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