STORE INSURANCE APPLICATION                         

Name of Association   ______________________________________________________

            Contact Name  _____________________________________________________

Name of Member       ______________________________________________________

            Address          ______________________________________________________

            City & State    ______________________________________________________

            Telephone    ___________________  Email ______________________________

Name of Store          _______________________________________________________

            Address       _______________________________________________________

            City & State _______________________________________________________

            Contact Name _____________________________________________________

            Telephone    ___________________ Email ______________________________

We the undersigned being duly elected officers/directors of the above named Association, do

hereby certify that ________________________________ is currently a member in good standing

and was also a member in good standing during he previous year.

                                     ____________________________    ______________________

                                                         Name                                         Title

                                     ____________________________    ______________________

                                                         Name                                         Title

I, ______________________________, do hereby certify that I have had no product liability

claims during the previous three years.

Please include one application and payment of $80.00 for each producer and store to be covered, i.e., one producer who wants coverage for 2 stores must submit 2 applications and pay $160.00.

Please return completed application and payment to:       
Marvin George, Jr.
2200 Lakeshore Dr. • Jacksonville, TX 75766 • (903)589-9292

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