Commercial – Venue Supplemental Application

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General Information
Name of applicant*
First Last
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Physical Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name of Contact*
First Last
Phone
Email*
Website
Business Type?*
- Corporation
- Partnership
- Individual
- Non-Profit
- Government Entity
Does the insured own or lease the facility?*
- Own
- Lease
Year business was established?*
Number of years under current management?*
FEIN*
Federal Employer Identification Number
Please list all Named Insureds and their Interests*
Named Insureds Interests

NOTE: The First Named Insured requires common/majority ownership of each named insured.

Named Insureds	Interests

Limit	Number of Employees

Carrier Name	Limit	Retroactive date

Self-Insured	Self-Funded