MOTORSPORTS Facilities & Events

Eligible Operations: No other organization has the knowledge and experience that allows K&K to provide superior coverage for world-renowned - Boat - Short track oval racing organizations as well as local tracks, teams and drivers. - Demo derbies racing K&K Insurance has provided insurance to the - - Racing associations industry since 1952 and is still the leader in the industry today. - Independent car - Road courses club activities - Snowmobile A wide range of products are available to protect motorsports - Karting competitions facilities and/or event promoters. From liability and participant - - Specialty accident coverages to property and commercial auto coverages, - Motorsports motorsports events K&K has it covered. Programs are available to cover facility country clubs - Super speedways operators, specialty event promoters and sanctioning - Motorsports driving - Tractor/truck pulls organizations. schools Coverages Available & Program Highlights:

General Liability Key Underwriting/Qualifying - Separate Limits for Legal Liability to Participants Factors (Including but not limited to): - Expanded Bodily Injury Definition - Must meet K&K insurability - Personal and Advertising Injury guidelines Definition Expanded - Official Vehicle Physical Damage Ineligible for this program: - Motorsports Errors & Omissions - Noncompetitive participation facilities - Customized Motorsport Policy Language (i.e., go kart concession tracks, off-road - Host Liquor Liability vehicle parks, mud parks)  - Cyber Risk ($25,000 sublimit) - Drag Participant Accident Coverage - Accidental Death & Specific Loss K&K Benefits: - Accident Medical Benefits Available on Excess - Experienced & professional staff dedicated or Primary Basis exclusively to servicing the K&K Motorsports - Limits up to $1,000,000 Programs for over 65 years - Volunteer- Accident Medical Coverage for - Attendance at industry conventions Motorsport Volunteers including RPM Promoters Workshops, - Weekly Accident Income Performance Racing Industry Trade Show Property (PRI) Crime - Active industry involvement through sanctioning bodies, racing associations and Inland Marine event attendance Commercial Auto - In-house underwriting, policy administration, Liquor Liability loss control and claims services - 24-hour emergency claims phone service Excess Liability - Insurance carriers rated “A” or higher by Event Cancellation & Non-appearance A.M. Best Workers Compensation - Interest-free premium installment plans available

Additional Products: - Contingency/Prize - High Limit Disability Indemnity - Products Liability - Employment Practices Liability

Insuring the world’s fun® Submission Instructions:

To request an insurance quotation through this program, please submit the appropriate applications along with the preliminary underwriting information listed. In some cases, requested coverages may not be offered or available due to underwriting criteria and/or carrier guidelines. It is important to carefully review the terms and conditions of any insurance quotations received. Please contact a K&K representative if you have any questions.

Preliminary Underwriting Information Required:

- K&K Application(s) (see below) - ACORD application(s) for other requested coverages - Five years of company loss runs - Diagram of event locations - Schedule of events - Copies of contracts where insured assumes liability of others

Motorsports Facilities & Events Application(s): Contact Information: (Applications can be obtained from our web site: kandkinsurance.com) 1712 Magnavox Way P.O. Box 2338 K&K Application(s) Fort Wayne, IN 46801-2338 - Motorsport Facilities Application (if needed) - Property Insurance Questionnaire (if needed) - Premises Liability Insurance Application (if needed) - General Application (if needed) - Permanent Facility Event Enrollment Form (if needed) Motorsports Facilities & Events - Temporary Event Motorsports Enrollment Form (if needed) Program - Liquor Liability (if needed) - Fireworks Application- Motorsports (if needed) PHONE: 800.348.1839 FAX: 260.459.5118 ACORD Application(s) - Property EMAIL: - Commercial Auto [email protected] - Crime - Inland Marine WEB SITE: kandkinsurance.com - Excess Liability

K&K Insurance Group, Inc. is a licensed insurance producer in all states (TX license #13924); operating in CA, NY and MI as K&K Insurance Agency (CA license #0334819)

Insuring the world’s fun® 12/20 GENERAL APPLICATION

Name of Insured (as will appear on policy): ______Doing Business As: ______Mailing Address: ______City: ______State: ______Zip: ______Phone: ( _____ ) ______Location Address (if different from above): ______City: ______State: ______Zip: ______Phone: ( _____ ) ______Contact Person: ______Person is: J Owner J Promoter J Agent J Other: ______Day Phone: ( _____ ) ______Night Phone: ( _____ ) ______Fax: ( _____ ) ______E-mail Address: ______Web Site Address: ______Name of Agency/Brokerage (if applicable): ______Contact Person: ______Mailing Address: ______City: ______State: ______Zip: ______Phone: ( _____ ) ______Fax: ( _____ ) ______E-mail address: ______Tax ID: ______Nature of operations/description of event: ______Insured is: J Corporation J Partnership J Joint Venture J Other (explain): J Limited Liability Corporation In what state is the organization headquartered/chartered? ______Policy period requested: From ______To ______Estimated number of events: ______

COVERAGE INFORMATION Check the type of coverage and indicate the limits desired: J General Liability J Primary ______J Excess ______J Legal Liability To Participants ______J Participant Accident and Health J AD&D ______

(Applicable only to Motorsports) J Primary Medical ______J Excess Medical ______J Weekly Disability Income ______J Property Casualty J Property______J Inland Marine ______J Auto ______J Workers’ Compensation J Other: ______1097 10/03 UNDERWRITING INFORMATION 1 . Has this type of insurance ever been: J Cancelled J Declined J Non-renewed If so, please explain. (Not applicable

in Missouri). ______

______2. Does this organization engage in any other business operations under the name of the insured as it will appear on the policy? J Yes J No If yes, please explain. ______3. As respects your operation(s), do you enter into any contracts? J Yes J No If yes, what contracts do you enter into? ______a. Does the Named Insured assume liability for the other party? J Yes J No PLEASE PROVIDE COPIES OF ALL CONTRACTS OF THIS TYPE. b. Does the other party assume the Named Insured’s liability? J Yes J No PLEASE PROVIDE ONE SAMPLE OF THIS TYPE. c. Does each party assume its own liability? J Yes J No 4. Who reviews the contracts prior to signing? J Corporate Officers J Counsel J Other (please explain) ______5. For each of the following, please indicate if there is a procedure in effect for obtaining certificates of insurance, the limits required for each and whether the certificates list the Named Insured as it will appear on the policy as an Additional Insured.

CERTIFICATES LIMITS ADDITIONAL INSURED (Provide copies.) Food Concessionaires ______Vendors/Exhibitors ______Contractors/Others ______

6. Is a K&K approved Waiver and Release form read and signed by all persons entering a restricted area prior to entry? (Applicable only to Motorsports) J Yes J No

PRIOR CARRIER INFORMATION (NEW BUSINESS ONLY) YEAR PREVIOUS AGENT COMPANY LIABILITY LIMITS PREMIUM LOSSES ______PLEASE SUBMIT A COPY OF PREVIOUS/PRESENT POLICY(IES)

I understand that the insurance company in determining whether to provide a quotation for insurance coverage will rely on the information contained in the application and all other information being submitted. I hereby warrant, represent and confirm that, to the best of my knowledge, all information provided is complete, true and correct.

______Applicant’s Signature Producer’s Signature (if applicable)

______Applicant’s Name (print) Producer’s Name (print)

______Date (MM/DD/YY) Date (MM/DD/YY) 1097 10/03 1712 Magnavox Way P.O. Box 2338 Fort Wayne, IN 46801-2338 KARTING (877) 355-0315 Fax (260) 459-5821 OPERATIONAL www.kandkinsurance.com CA# 0334819 QUESTIONNAIRE

Applicant Name: Web site:

OPERATION INFORMATION 1. Business Hours: 2. Programs offered: q groups q racing programs q team building q other (please list)

3. Minimum age of participant: Please list any other age restrictions: 4. Minimum height of participant: Please list any other height restrictions: 5. Include a copy of the local or state certificate, license and or permit granting you approval to operate. If not required, please explain:

6. Are there any open loss control or inspection items? q Yes q No If yes, please describe:

7. Are all karts equipped with a safety harness and roll bar? q Yes q No If no, please describe:

8. List personal safety equipment required: (helmets, head sock, racing suit, gloves etc.)

9. List personal safety equipment required supplied by you:

10. Describe pre-session training:

11. Is a race licensing program in place? q Yes q No

12. Provide projected receipts for all activities: Total Karting receipts $ Percentage of these receipts from individual rentals % Percentage of these receipts from racing leagues % Percentage of these receipts from team building % Food receipts $ Liquor receipts $ Arcade receipts $ Conference/Party Room rental receipts $ OTHER, please explain and provide receipts $

13. Provide your financial reports or your D&B rating 1388 4/18 14. Is an employee handbook available? q Yes q No

If Yes, please provide a copy 15. Provide diagram of track showing the following: a. Barrier type and locations. b. Fire extinguisher locations. c. Fuel storage tank location (for gas karts). d. Battery re-charge stations (for electric karts). e. Spectator viewing areas with protection. IF INDOOR OPERATIONS, PLEASE ANSWER QUESTIONS 16 – 22.

16. What is the age of building:

17. What is the size of building: s.f.

18. Size of area used for karting: s.f.

19. Is building air exchange system in place? q Yes q No 20. What is the air exchange rate per hour?

21. How often is air quality checked?

22. Is battery recharge area ventilated? q Yes q No

23. Is there a procedure for maintenance and cleaning of all karting operations? q Yes q No If Yes, please describe:

24. ADULT KARTS Kart type q Gas q Electric Manufacturer: Model: Horsepower: Maximum Speed: Operator: Minimum age Minimum height Total number of adult karts: YOUTH KARTS Kart type q Gas q Electric Manufacturer: Model: Horsepower: Maximum Speed: Operator: Minimum age Minimum height Total number of youth karts:

25. Are adult and youth karts allowed on the track at the same time? q Yes q No 26. Total number of karts allowed on the track at any one time:

27. Number of on track monitors:

28. Are all of the moving engine parts guarded to prevent hair entanglement? q Yes q No 29. Provide kart maintenance schedules and inspection schedules

30. Provide copy of posted rules and regulations.

31. Does each kart have a manufacturer approved gas (if gas) filler cap? q Yes q No 32. Explain refueling/recharging procedures and location:

1388 4/18 ANCILLARY ACTIVITIES: RESTAURANT / SNACK BAR q Not applicable

1. What is the food and beverage exposure? q Full Service q Snack Bar q Sub-contracted (Lessor’s Risk only)

2. Indicate which of the following apply and the number of each: q Ranges q Ovens

q Deep Fryers q Grills q Broilers q Griddles

3. Are all cooking surfaces properly fire protected? q Yes q No

4. Are portable “K” fire extinguishers provided in the kitchen? q Yes q No

5. What type of Automatic Extinguishing System (AES) is in place? q Wet q Dry

6. Do you have a contract for servicing and maintaining the Automatic Extinguishing System? q Yes q No

7. How often is this serviced and maintained? q Monthly q Quarterly q Semi-Annually q Annually

8. Do you have a contract for cleaning hoods and ducts? q Yes q No

9. How often are hoods and ducts cleaned? q Monthly q Quarterly q Semi-Annually q Annually 10. How often are filters cleaned?

11. Will beer or liquor be sold? q Yes q No Who holds the valid license?

Total liquor receipts: $ Total food receipts: $

12. Have all alcohol servers had alcohol awareness training? q Yes q No 13. Explain alcohol / driving controls:

14. Do you obtain certificates from contractor(s) and vendor(s)? q Yes q No

CLIMBING WALLS q Not applicable 1. Who built the walls?

2. What safety equipment will participants be using?

3. Is there some type of safety back-up (describe)?

4. How many participants are anticipated during policy period?

5. Please provide a copy of any waiver/release you propose to use.

6. Please provide diagram and photos of the wall along with any brochures produced.

7. Provide manufacturer name and age of harness equipment.

8. Provide picture of base fall protection.

9. Is belay system manual or automatic?

10. What is the wall height?

11. How many climbers will wall accommodate at one time? 1388 4/18 ZIP LINES q Not applicable 1. Who constructed the line?

2. Completely describe the area, type and height of the element.

3. Include photos of the zip line equipment, course and starting point signage.

4. How often do you inspect the equipment?

5. Is the course inspected annually by a certified independent consultant? q Yes q No If yes, what certification do they have (AEE, PRCA, or ACCT/PVM)

6. Describe staff training (by whom, how often).

7. Are all staff members included in the training? q Yes q No 8. Please provide a copy of the waiver/release you use.

9. Please provide a copy of the rules and regulations.

10. Please provide a copy of any brochures

By signing this questionnaire the undersigned declares, to the best of his/her knowledge, all statements to be true, complete and accurate. The completion and submission of this questionnaire shall not be binding to the prospective insured or the company until coverage is confirmed bound by the insuring company.

Applicant’s Signature Date

1388 4/18 1712 Magnavox Way P.O. Box 2338 PROPERTY INSURANCE Fort Wayne, Indiana 46801 QUESTIONNAIRE (800) 348-1839 Fax (260) 459-5118 www.kandkinsurance.com CA #0334819

GENERAL INFORMATION Named Insured: Contact Person: Title: Mailing Address:

Phone ( ) Fax ( ) Email:______Property Location #1:

Property Location #2:

Prior/Current Insurance Carrier: Prior Losses/Claims: Expiration Date of Current Policy: Years in Business:

PROPERTY Amount of Insurance Coverage for: ❏ Replacement Cost ❏ Actual Cash Value Deductibles: Coinsurance:

Limits: Building #1: Contents #1: Building Construction Type: Year Built: Area: Type of Fire/Burglar Protection: Location:

Limits: Building #2: Contents #2: Building Construction Type: Year Built: Area: Type of Fire/Burglar Protection: Location:

Limits: Building #3: Contents #3: Building Construction Type: Year Built: Area: Type of Fire/Burglar Protection: Location:

Limits: Building #4: Contents #4: Building Construction Type: Year Built: Area: Type of Fire/Burglar Protection: Location: 1134 10-03 page 1 of 5 SIGNS (list and describe signs not attached to buildings):

GLASS (Panes worth more than $1,000 and all Thermal, Double and Triple Pane glass-List # of panes, width and height of each):

BUSINESS INCOME Business Income coverage is an extension of Property Coverage that will pay for the actual loss of Business Income you sustain due to the necessary suspension of your “operations” during the “period of restoration.” The suspension must be caused by direct physical loss of or damage to property at the premises described in the policy subject to any applicable exclusions. Please indicate if you are interested in this coverage: ❏ Yes ❏ No

BUSINESS AUTO Liability Coverage: Combined Single Limit: We will automatically include Uninsured/Underinsured Motorist and Medical Payments coverages unless noted otherwise.

List of Vehicles: Deductibles* Where Year Make/Model VIN Number Cost New* Comprehensive / Collision Garaged ** 1. 2. 3. 4. 5. 6.

* Cost New and Deductibles are needed when insuring the vehicle for Comprehensive and Collision Physical Damage coverage. ** Garaging needs to list City, State and Zip Code. If all vehicles are garaged in the same location you may only list once.

1134 10-03 page 2 of 5 Non-Owned/Hired Auto Liability Limit: Number of Employees Hire Care Physical Damage Limit: Deductible: Comp. Collision: CRIME Form A (Employee Dishonesty): LImit: Deductible: Form C (Theft, Disappearance & Destruction): Inside Limit: Deductible: Outside Limit: Deductible: Form Q (Robbery & Safe Burglary-Money & Securities): Inside Limit: Deductible: Outside Limit: Deductible: Explain Security/Safe Protection:

WORKERS COMPENSATION Employer’s Liability Limits: $ Each Accident $ Disease - Policy Limit $ Disease - Each Employee RATING INFORMATION Categories/Duties/ Number of Est. Annual Job Classifications Employees Remuneration

Individuals Included/Excluded: Partners, Officers, Relatives to be included in or excluded from coverage (To be included Remuneration must be part of rating information section.) Date Title/ Incl./ Name of Birth Relationship Ownership % Excl.

1134 10-03 page 3 of 5 General Information: 1) Do you have any Seasonal Help? ❏ Yes ❏ No If yes, how many: 2) Is there any Volunteer or Donated labor? ❏ Yes ❏ No If yes, how many: 3) Are subcontractors used? ❏ Yes ❏ No If yes, are certificates of insurance on file? ❏ Yes ❏ No

INLAND MARINE (Equipment that can be taken off-premises including Mobile Equipment not included as Contents under the Property Coverage. For Race Teams, include the competition vehicle, tools, misc. equipment and spare engine that leave your premises.)

Scheduled Miscellaneous Articles Limit: Deductible: Equipment Schedule: Number Year Make/Model ID Number Value

Large items with significant value should be scheduled above.

Unscheduled Miscellaneous Articles Limit: Deductible: Amt. of Most Valuable Item: Limit should include smaller value items such as tools.

Electronic Data Processing equipment Limit: Deductible: Equipment Schedule: Number Year Make/Model ID Number Value

1134 10-03 page 4 of 5 LOSS HISTORY Enter all claims or occurrences that may give rise to claims for the prior 5 years. ❏ Check here if none ❏ See attached loss summary

Date of Type/Description of Date of Amount Amount Occurrence Occurrence or Claim Claim Paid Reserved

I understand that the insurance company in determining whether to provide a quotation for insurance coverage will rely on the information contained in the application and all other information being submitted. I hereby warrant, represent and confirm that, to the best of my knowledge, all information provided is complete, true and correct.

______Applicant’s Signature Producer’s Signature (if applicable)

______Applicant’s Name (print) Producer’s Name (print)

______Date (MM/DD/YY) Date (MM/DD/YY)

1134 10-03 page 5 of 5 1712 Magnavox Way FINANCIAL Fort Wayne, Indiana 46801 (800) 348-1839 Fax (260) 459-5118 REPORTING www.kandkinsurance.com FORM CA# 0334819 Valuation Date: ASSETS LIABILITIES AND SHAREHOLDERS’ EQUITY CURRENT ASSETS CURRENT LIABILITIES Cash and cash equivalents Short-term borrowings Marketable securities (readily sellable) Trade accounts payable Accounts receivable Other current liabilities Inventories Income taxes payable Deferred income taxes Current maturities of long-term debt Prepaid expenses and other current assets

TOTAL CURRENT ASSETS TOTAL CURRENT LIABILITIES

PROPERTY, PLANT AND EQUIPMENT LONG-TERM DEBT Land and land improvements Building and improvements SHAREHOLDERS’ EQUITY Construction in progress Paid-in capital Machinery and other equipment Retained earnings Leasehold improvements Accumulated other comprehensive income (loss) Accumulated depreciation and amortization

OTHER ASSETS Deferred income taxes Miscellaneous other assets

TOTAL ASSETS TOTAL LIABILITIES AND SHAREHOLDERS’ EQUITY

NET SALES Costs and expenses: 1. Have you ever gone through bankruptcy or had a judgement against you? Yes No Cost of sales Selling, general and administrative expenses 2. Are any assets pledged or debts secured? Yes No Operating Income Other income (expenses): Interest and dividends Interest expense Other income Income before income taxes Income taxes NET INCOME The foregoing statement, submitted for the purpose of obtaining insurance, is true and correct in every detail and fairly shows my financial condition at the time indicated. I will give you prompt written notice of any subsequent substantial change in such financial condition occurring before discharge of my obligations to you. I understand that you will retain this personal financial statement whether or not you approve the insurance in connection with which it is submitted. K&K Insurance Group, Inc. is authorized to verify any information contained herein including but not limited to my credit and employment history and to request, obtain, and use credit information on me in the processing of my application. This document, or any photostatic copy hereof, hereby authorizes any third party to furnish to K&K Insurance Group, Inc. with complete consumer credit reports. THE UNDERSIGNED CERTIFY THAT THE INFORMATION CONTAINED ON THIS FORM HAS BEEN REVIEWED AND THAT IT IS TRUE AND CORRECT IN ALL RESPECTS.

Signature Date

Name (print) 1241 6/04 MANDATORY SIGNATURE SUPPLEMENT THE NOTICES CONTAINED ON THIS SUPPLEMENT APPLY TO ALL UNDERWRITING INFORMATION BEING SUBMITTED TO K&K INSURANCE GROUP, INC., INCLUDING APPLICATIONS, QUESTIONNAIRES AND ENROLLMENT FORMS, FOR THE FOLLOWING PERSON OR ENTITY: Applicant name: FRAUD WARNING Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act. Applicable in AL Applicable in NM Any person who knowingly presents a false or fraudulent claim for payment of Any person who knowingly presents a false or fraudulent claim for payment a loss or benefit or who knowingly presents false information in an application of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or for insurance is guilty of a crime and may be subject to civil fines and criminal confinement in prison, or any combination thereof. penalties. Applicable in AR, LA, MD, RI and WV Applicable in NJ Any person who knowingly (or willfully)* presents a false or fraudulent claim for Any person who includes any false or misleading information on an application for payment of a loss or benefit or knowingly (or willfully)* presents false information an insurance policy is subject to criminal and civil penalties. in an application for insurance is guilty of a crime and may be subject to fines and Applicable in NY confinement in prison. *Applies in MD Only. Any person who knowingly and with intent to defraud any insurance company or Applicable in CO other person files an application for insurance or statement of claim containing It is unlawful to knowingly provide false, incomplete, or misleading facts any materially false information, or conceals for the purpose of misleading, or information to an insurance company for the purpose of defrauding or information concerning any fact material thereto commits a fraudulent insurance attempting to defraud the company. Penalties may include imprisonment, fines, act, which is a crime, and shall also be subject to a civil penalty not to exceed five denial of insurance and civil damages. Any insurance company or agent of an thousand dollars and the stated value of the claim for each such violation. insurance company who knowingly provides false, incomplete, or misleading Applicable in OH facts or information to a policyholder or claimant for the purpose of defrauding or Any person who, with intent to defraud or knowing that he is facilitating a fraud attempting to defraud the policyholder or claimant with regard to a settlement or against an insurer, submits an application or files a claim containing a false or award payable from insurance proceeds shall be reported to the Colorado Division deceptive statement is guilty of insurance fraud. of Insurance within the Department of Regulatory Agencies. Applicable in OK Applicable in DC WARNING: Any person who knowingly, and with intent to injure, defraud or WARNING: It is a crime to provide false or misleading information to an insurer deceive any insurer, makes any claim for the proceeds of an insurance policy for the purpose of defrauding the insurer or any other person. Penalties include containing any false, incomplete or misleading information is guilty of a felony. imprisonment and/or fines. In addition, an insurer may deny insurance benefits Applicable in PA if false information materially related to a claim was provided by the applicant. Any person who knowingly and with intent to defraud any insurance company or Applicable in FL other person files an application for insurance or statement of claim containing Any person who knowingly and with intent to injure, defraud, or deceive any materially false information or conceals for the purpose of misleading, any insurer files a statement of claim or an application containing any false, information concerning any fact material thereto commits a fraudulent insurance incomplete, or misleading information is guilty of a felony of the third degree. act, which is a crime and subjects such person to criminal and civil penalties. Applicable in KY Applicable in OR Any person who knowingly and with intent to defraud any insurance company Any person who knowingly and with intent to defraud or solicit another to defraud or other person files an application for insurance containing any materially false the insurer by submitting an application containing a false statement as to any information or conceals, for the purpose of misleading, information concerning material fact may be violating state law. any fact material thereto commits a fraudulent insurance act, which is a crime. Applicable in VA Applicable in ME, TN, and WA It is a crime to knowingly provide false, incomplete or misleading information to an It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include insurance company for the purpose of defrauding the company. Penalties (may)* imprisonment, fines and denial of benefits. include imprisonment, fines and denial of insurance benefits. *Applies in ME Only. FRAUD APPS (2019/11) I understand that K&K Insurance Group, Inc., for the insuring company, shall be permitted but not obligated to inspect a proposed insured’s, or an insured’s, property and operations for underwriting purposes at any time. Neither the right to make an underwriting inspection nor the making thereof nor any report thereon shall constitute an undertaking, on behalf of or for the benefit of any insured, or other, to determine or warrant that such property or operations are safe or healthful, or in compliance with any standards, rules or regulations. Underwriting inspections when conducted are for the sole purpose of determining and/or improving the insurability of certain property and operations and not safety. I also understand that an insured is solely responsible for the safety of its facilities and operations and shall not rely upon any underwriting inspections to determine the safety of its facilities or operations and shall not diminish or forego its own safety practices and procedures. I understand that the insurance company in determining whether to provide a quotation for insurance coverage will rely on the information contained in the application and all other information being submitted. I hereby warrant, represent and confirm that, to the best of my knowledge, all information provided is complete, true and correct. I also understand that no insurance will be in effect unless and until the insurance company, or K&K as its agent, provides a quotation offering to provide insurance coverage and the insurance company, or K&K as its agent, receives written notice that the terms and conditions contained in the insurance quotation provided are accepted.

______APPLICANT’S SIGNATURE PRODUCER’S SIGNATURE (if applicable)

______PRINT NAME PRINT NAME

______DATE (MM/DD/YY) DATE (MM/DD/YY) 1030 12/20