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Tenant User Information		Credit Card Billing Information
First Name:		First Name:
Last Name:		Last Name:
Phone Number:		Phone Number:
Fax Number:		Fax Number:
Company:		Company:
Address:		Address:
City:		City:
State:		State:
Zip/Postal Code:		Zip/Postal Code:
User e-mail (if different):		Bill E-mail (if different):

LEGAL NOTICES: Insurance is valid in the United States only. No coverage is provided by this policy unless an online application has been submitted and a premium has been paid. No coverage is provided for Liquor Liability or Excess Liability Coverage unless the submitted application includes an additional premium payment. No coverage is provided by this policy for paid professional entertainment or talent unless specifically endorsed hereon. This insurance does not apply to “bodily injury” or “personal injury” or death of any person while rehearsing or practicing for, participating in, or traveling to and from any contest or exhibition of an athletic, dance or sports nature. Coverage may be offered by or placed through more than one insurance carrier.

URMIA is acting only as a buyer or advertiser of certain coverage on behalf of its members and not as a broker or agent to, or as any insurance company.

Issuance of the Insurance Binder and/or the Certificate of Insurance does not guarantee a TULIP User use of the Institution’s facilities. The Institution must approve all use of their campus facilities prior to the purchase of insurance.

Refund Policy: Refunds for cancellations other than rain only if notification is given to Bene-Marc, Inc. in writing one full business day (24 hours) before the date of the insured event. Rain cancellations must be reported to Bene-Marc within 24 hours.

General Liability is placed with Praetorian Insurance Company.

Excess Accident Medical is written by ACE American Life Insurance Company.