Vendor Application

Requested Start Date *
We are not able to back date insurance. What date would you like your insurance to start?
E.g., 01/19/2021
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
E.g., 01/19/2021

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

I opt in to receive marketing emails from Specialty Insurance Agency. Consent maybe revoked at anytime by clicking the unsubscribe link at the bottom of every email.

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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