ࡱ> q` jbjbjqPqP ~::#8T5HvN TQ"F.H.H.H./w.41446h94$$$4x5&&&$XF.&$F.&&:+,2,< @ ^$d+ -L505+R9$92,92,"0-#"&O#k#"""44^&X"""5$$$$ $ CENTURY SURETY COMPANY GENERAL LIABILITY APPLICATION FOR CHRISTMAS TREE FARM / LOT  FORMTEXT       1. Name of Applicant: 2. Applicant is:  FORMCHECKBOX  Individual  FORMCHECKBOX  Partnership  FORMCHECKBOX  Corporation  FORMCHECKBOX  For Profit  FORMCHECKBOX  Non-Profit  FORMTEXT       3. Mailing Address:  FORMTEXT       4. List of farm(s) or lot(s) addresses if different from mailing address:  FORMTEXT       5. Name of Membership Association you belong to: 6. Interest of Named Insured in Premises:  FORMCHECKBOX  Owner  FORMCHECKBOX  Lessee  FORMCHECKBOX  Other ___________________ 7. Type of business:  FORMCHECKBOX Choose & Cut Receipts)  FORMTEXT        FORMCHECKBOX Retail Lots  FORMCHECKBOX Wholesale Broker No. of Acres  FORMTEXT       No. of Lots  FORMTEXT       Receipts)  FORMTEXT       8. Optional coverage available, check box to purchase coverage: (R = gross receipts)  FORMCHECKBOX Hay or Sleigh Rides R)  FORMTEXT        FORMCHECKBOX Pumpkin Patches R)  FORMTEXT        FORMCHECKBOX Haunted Houses R)  FORMTEXT        FORMCHECKBOX Maze R)  FORMTEXT        FORMCHECKBOX  Pesticide/herbicide  FORMCHECKBOX School Tours R)  FORMTEXT        FORMCHECKBOX Gift Shop R)  FORMTEXT        FORMCHECKBOX Other R)  FORMTEXT       Other, explain in detail  FORMTEXT       COVERAGE INFORMATION 10. Dates Coverage Required: From:  FORMTEXT       To:  FORMTEXT       Limits Required-New Liability Form: Each Occurrence  FORMTEXT 1,000,000 General Aggregate:  FORMTEXT 1,000,000 Deductible: $250  FORMCHECKBOX  $500  FORMCHECKBOX  Medical Payments Coverage is excluded 11. Additional Insured: Name and Address Interest  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       12. If coverage is provided, it will contain special exclusions (above and beyond normal policy exclusions) including, but not necessarily limited, to the following: A. Riot and Civil Commotion B. Assault and Battery C. Injury to persons in unauthorized areas D. Unscheduled Events E. Fireworks demonstrations or displays F. Injury to Participants or damage to their property G. Operation of any aircraft or passenger carrying balloons H. Operation of autos, motorized vehicles, animal rides, trampolines or mechanically operated amusement rides unless authorized by specific endorsement I. Use of saddle animals and horse drawn hayrides J. Loaning, renting, maintenance of use by others of any power driven equipment, hatchets, axes or chainsaws 13. Previous Insurer(s)  FORMTEXT       Policy Number(s)  FORMTEXT       Were there any losses?  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Restricted areas will be clearly marked. Removal of ice and snow from roadways, paths, sidewalks and parking lots. If herbicide and pesticide coverage is purchased, insured agrees to mix, use and store according to EPA standards. Customers will be restricted to cutting trees with a hand saw only. Animals are to be in a secure area and supervised. ________initial The applicant, Agent or Broker represents that the above statements and facts are true and that no material facts have been suppressed or misstated. Completion of this form does not bind coverage or commit the company to policy issuance. Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits and application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Applicant:  FORMTEXT       Producer:  FORMTEXT       Signature: ___________________________________ Signature: ___________________________________ Date:  FORMTEXT       Date:  FORMTEXT       By applying for this insurance the applicant also is applying for membership in the American Christmas Tree Risk Purchasing Group, LLC, a purchasing group formed and operating pursuant to the Liability Risk Retention Act of 1986 (15 USC 3901 et seq.).  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