Vendor Application

Requested Start Date *
What date would you like your insurance to start?
E.g., 11/22/2019
Select Annual Policy
(Coverage is for a single event that runs up to 10 days.)

Fill in the information below COMPLETELY.
Print out the application & mail with your check.
Make your check or money order made payable to Vendors of the U.S.

Mail to: Specialty Insurance Agency
P.O. Box 24
New Richmond, WI 54017-0024

Please Enter State Abbreviation Ex: Florida = FL
Please list all property that you need covered under your Inland Marine policy
Date
E.g., 11/22/2019

Please Note: Product coverage is not available if you are selling: firearms, fireworks, swords, knives, infant products, medical products, nutritional products & supplements.


Clear signature
Click and hold down your left mouse button inside the Client Signature box. Use your mouse curser as a pen to write your name. When done, simply let go of your left mouse button.

REQUIRED FIELD - If the signature box is left blank we are unable to process your application.

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