Prize Indemnity Application

Prize Indemnity Application

Producer Company: American Standard Management Services, Inc., Producer Name: Ryan E. Hill, Telephone: 719-685-2531, Email: Info@ASMSInsurance.com, Mailing Address: 111 S. Tejon St., # 404, Colorado Springs, CO 80903, Fax: 719-577-2520

1. Name of Company or Organization (Proposed Assured) applying for Insurance:

Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

2. Name of the Event/Promotion?

3. Type of event/promotion (what is the contest that will be rewarded with the prize)?

4. Date(s) and location of the event/promotion:

5. What is the value of the available prize(s) to be insured?

6. Please provide the full details of how prize(s) will be won:

7. Estimated number of participants:

8. Number of game pieces to be distributed (if applicable):

9. Have you had past experience holding events/promotions of this kind?

Yes
No

If yes, please provide details below:

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10. Within the last five (5) years, has the Proposed Assured ever filed an Insurance claim for a similar event/promotion?

Yes
No

If yes, please detail the weather conditions which would cause the event to be canceled below:

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11. Has the Proposed Assured ever had similar Insurance (as applied for herein) declined, canceled or renewal refused?

Yes
No

If yes, please provide details below:

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12. Are Official Rules available?

Yes
No

If yes, please type the rules below, provide a copy with this application or email to info@asmsinsurance.com and reference this application.

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DECLARATION

To the best of my knowledge and belief the information provided in this application, whether in my own hand or not, is true and I have not withheld any material facts.

I understand that non-disclosures or misrepresentation of material fact will entitile the Company to void the insurance.

I understand that signing this Application does not bind me to complete the insurance but agree that should an insurance policy be issued, this Application and the statements made therein shall form the basis of the insurance policy.

Name

First Name Last Name

TITLE:

DATE:

PHONE NUMBER:

Email Address

Word Verification

Type the words you see above separated by a space.
Letters ARE case-sensitive.