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2019kkapplication

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1629 5/18
PROGRAM DESCRIPTION
This program has been designed for exhibitors and/or
vendors who are displaying, demonstrating or promoting
their products or services at the 2019 Unied Wine & Grape
Symposium.
Coverage is provided by a carrier currently rated A+
(Superior) by A.M. Best Company.
INELIGIBLE OPERATIONS
UNIFIED WINE & GRAPE SYMPOSIUM, LLC EXHIBITOR
Insurance Program Brochure and Enrollment Form
This brochure is valid for effective dates from 1/27/19 through 2/2/19
This brochure is for illustrative purposes only and is not a
contract of insurance. You must refer to the actual policy for
complete information regarding coverage terms, conditions
and exclusions as they may change from one coverage
period to the next. You may request a copy of the full policy
by submitting a written request to us.
EASY WAYS TO ENROLL FOR COVERAGE
FAX 1-260-459-5502
Regular:
K&K Insurance
Event RPG
P.O. Box 2338
Fort Wayne, IN 46801-2338
E-MAIL info@eventinsurance-kk.com
Submit this enrollment form, with payment, to K&K.
QUESTIONS Call 1-800-328-2317
Overnight:
K&K Insurance
Event RPG
1712 Magnavox Way
Fort Wayne, IN 46804
MAIL
• Antiques & collectibles
• Apparel & accessories
• Arts & crafts
• Auto/vehicle accessories
(non-mechanical)
• Candles
• Caterers
• Celebrity, mascot or
character appearances
• Cleaning accessories
& products
• Exercise equipment
• Floral
• Food, drink or produce sales
• Game trailers or booths
• Gift wrap booths
• Hardware sales
• Health & beauty products
• Home-based vendors
(caterers,DJs, orists, ice
sculptors, decorators,
photographers/videographers)
• Kitchen or cookware
accessories or appliances
• Lawn & garden equipment
• Literature distribution
• Micro reality race tracks
• Motorized equipment –
static display
• Product demonstrations
• Product or service displays
• Souvenir sales
• Sports or camping
equipment
• Toys (for ages 5 and over)
• Vehicle/boat display -
static only
ELIGIBLE OPERATIONS
• On-site equipment sales
& rental
• Oxygen or aromatherapy
bars
• Paintball equipment/
accessories
• Photographers (except for
a single event home-based
photographer)
• Protective equipment or
apparel
• Storefront operations
• Tobacco products (including
e-cigarettes/vapor products)
• Toys (for ages 4 and under)
• Unmanned aircraft systems
(e.g.: drones, RC aircrafts)
• Vehicles in motion
• Watercraft exhibits on water
• Weapon sales
• Weight loss plans or
products (selling)
• Wholesale business
operations
• Alcoholic beverages -
selling or furnishing
• Animals
• Auto parts (mechanical)
• Body piercing or
permanent tattooing
• Christmas tree retail lots
• Contractors (lighting,
stage, sound, etc.)
• Cryogenic chambers/
therapy
• E-commerce selling
• Fire safety equipment
• Fireworks sales &
displays
• Haunted attractions
• Hot wax impressions
• Leasing/rental operations
• Mazes (corn, hay, fence)
• Medical testing
• Motorsports activities
• Nutritional or health
supplements (selling)
• On-site installation, service
or repair of products
Operations not eligible for this program include, but are not
limited to the following:
FOR SERVICE REQUESTS ONLY
Page 2 of 7
EXCLUSIONS
COVERAGES AND LIMITS
1629 5/18
The following represent only some of the exclusions contained in this policy.
• Abuse, molestation, harassment
or sexual conduct
• All operations listed as ineligible
• Amusement devices (e.g.: rides, slides,
inatables, bungees, climbing walls,
dunk tanks-does not apply to structures
that are not designed to bounce on, slide
on, ride on or tunnel through)
• Animals (injury or death to any
animal or injury, death, or property
damage caused by your animal)
• Asbestos
• Employment-related
practices
• Fireworks
• Fungi or bacteria
• Lead
• Nuclear energy liability
*Cost includes premium and a $15 risk purchasing group administration fee.
FREQUENTLY ASKED QUESTIONS
1. How soon does coverage start? When will we
receive proof of coverage?
Coverage can be bound the date after we receive a
completed enrollment form and the appropriate
premium. Please allow adequate time for us to process
your enrollment form and issue certicates.
2. What is a general aggregate?
The general aggregate is the maximum amount to
be paid out in any policy period for all losses.
3. Will we receive a policy after submitting the
enrollment form?
You will receive a certicate of insurance as proof
of coverage. Coverage is offered exclusively through
Sports, Leisure and Entertainment Risk Purchasing
Group (RPG). The RPG receives a master policy
from the company. Submission of this enrollment form
conrms your desire to receive coverage through the
RPG. Each member receives their own certicate of
insurance as their evidence of coverage. The limits of
insurance apply individually to each insured member
organization-there are no shared limits of liability with
any other members. A copy of the RPG master policy
can be requested in writing to: K&K Insurance Group,
Inc., 1712 Magnavox Way, Fort Wayne, IN 46804.
Commercial General Liability
Each Occurrence $ 1,000,000
General Aggregate (other than Products-completed Operations) $ 5,000,000
Products-completed Operations Aggregate $ 1,000,000
Personal and Advertising Injury $ 1,000,000
Damage to Premises Rented to You (Fire Legal Liability) $ 300,000
Medical Expense
$ 5,000
Cost* $ 130.00
Commercial General Liability with Broadening Endorsement – coverage which protects the insured against liability
claims for bodily injury and property damage arising out of premises, operations, products and completed operations and
personal and advertising injury.
COSTS ARE 100% FULLY EARNED AND NON-REFUNDABLE ONCE COVERAGE BEGINS. COVERAGE
IS CONTINGENT UPON RECEIPT OF PAYMENT. NO COVERAGE WILL BE DEEMED IN EFFECT UNTIL
THE ACCURATE PAYMENT IS RECEIVED BY THE COMPANY OR THEIR REPRESENTATIVE.
Page 3 of 7
Enrollment Form - Unied Wine & Grape Symposium LLC Exhibitor
Valid for effective dates from 1/27/19 through 2/2/19
GENERAL
INFORMATION
Completion of this enrollment form conrms your desire to obtain insurance through the Sports, Leisure and Entertainment
Risk Purchasing Group. A risk purchasing group (RPG) provides group purchasing power for similar risks resulting in potential
advantageous coverage terms, competitive rates, risk management bulletins, and rewards for favorable group loss experience.
An RPG administration fee may be charged. The submission of this enrollment form and/or the acceptance of payment does
not guarantee coverage. Certain operations are not eligible for coverage by this program. We reserve the right to decline any
request for coverage.
TO AVOID PROCESSING DELAYS, PLEASE: 1. Complete all sections (print legibly)
2. Sign and date where required
3. Remit completed enrollment form (pages 3-7) with payment
K&K Insurance Group, Inc. • P.O. Box 2338 • Fort Wayne, IN 46801-2338 • 1-800-328-2317 • Fax 1-260-459-5502
www.kandkinsurance.com
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)
1629 7/17
a
BUSINESS & COST
INFORMATION
Name of event: ___________________________________________________________________________
Date(s) of event (including set-up and tear-down days): ______/______/______ to ______/______/______
Location of event: __________________________________________________________________________
Check all that apply regarding your type of operations:
m Selling products/services
Describe product/service: ______________________________________________________________________
m Distribution of literature and/or display only
Describe product/service being displayed/information being provided: ___________________________________
Cost for 10 x 10 sq. ft. booth: $130.00 (includes RPG administration fee)
Unied Wine & Grape Symposium 2019
1 27 19 2 1 19
Sacramento Convention Center, 1400 J Street Sacramento, CA 95814
m I am a new account m I am renewing my coverage
Full legal name of business: ___________________________________________________________________________
Note: This is the name that will appear on your Certicate of Insurance. If your company is a Sole Proprietorship, then this will be your personal name
or DBA.
Applicant is a: m Sole Proprietorship m Limited Liability Co. m Corporation m Partnership
m Other (describe): __________________________________________________________________
Mailing address: ____________________________________________________________________________________
City: ________________________________________________________ State: ________ Zip: __________________
Contact name: ______________________________________ Phone: (______) _______________________________
Cell: (______) ___________________________________ Fax: (______) _______________________________________
E-mail: __________________________________________ Website: _________________________________________
(By listing an email address, you are giving us permission to contact you by email about your policy. Refer to page 5 of the application for Electronic
Disclosure and Consent)
Unied Wine & Grape Symposium, LLC, the City of Sacramento, Sacramento Convention & Visitors Bureau, and the
Sacramento City Public Facilities Financing Corporation will automatically be provided additonal insured certicates,
along with policy endorsement CG-2026 & SRPG8018. Complete this section to request additional certicates. Provide
separate requests for each additional certicate needed.
Check the type of certicate you are requesting:
m Additional insured m Evidence of coverage
Certicate holder information:
Entity name: ___________________________________________________________________________________
Complete mailing address: ________________________________________________________________________
Relationship to named insured:
m Sponsor m Co-promoter m Franchisor m Other (please identify/explain):_____________
Other than being named on the certicate as an additional insured or certicate holder, does the person or organization require
any special wording or endorsements?
m Yes m No If yes, please describe:____________________________________
CERTIFICATE REQUESTS
Page 4 of 7
1629 5/18
GENERAL FRAUD STATEMENT
Applicable in AL, AR, DC, LA, MD, NM, RI and WV
Any person who knowingly (or willfully)* presents a false
or fraudulent claim for payment of a loss or benet or
knowingly (or willfully)* presents false information in an
application for insurance is guilty of a crime and may be
subject to nes and connement in prison. *Applies in MD
Only.
Applicable in CO It is unlawful to knowingly provide
false, incomplete, or misleading facts or information to
an insurance company for the purpose of defrauding
or attempting to defraud the company. Penalties may
include imprisonment, nes, denial of insurance and
civil damages. Any insurance company or agent of
an insurance company who knowingly provides false,
incomplete, or misleading facts or information to a
policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claimant with
regard to a settlement or award payable from insurance
proceeds shall be reported to the Colorado Division of
Insurance within the Department of Regulatory Agencies.
Applicable in FL and OK Any person knowingly and
with intent to injure, defraud, or deceive any insurer les a
statement of claim or an application containing any false,
incomplete, or misleading information is guilty of a felony
(of the third degree)*. *Applies in FL Only.
Applicable in KS Any person who knowingly and with
intent to defraud, presents, causes to be presented or
prepares with knowledge or belief that it will be presented
to or by an insurer, purported insurer, broker or any
agent thereof, any written, electronic, electronic impulse,
facsimile, magnetic, oral, or telephonic communication
or statement as part of, or in support of, an application
for the issuance of, or the rating of an insurance policy
for personal or commercial insurance, or a claim for
payment or other benet pursuant to an insurance policy
for commercial or personal insurance which such person
knows to contain materially false information concerning
any fact material thereto; or conceals, for the purpose
of misleading, information concerning any fact material
thereto commits a fraudulent insurance act.
Applicable in KY, NY, OH and PA Any person who
knowingly and with intent to defraud any insurance
company or other person les 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, which is a crime and subjects
such person to criminal and civil penalties* (not to exceed
ve thousand dollars and the stated value of the claim for
each such violation)*.*Applies in NY Only.
Applicable in ME, TN, VA and WA It is a crime to
knowingly provide false, incomplete or misleading
information to an insurance company for the purpose
of defrauding the company. Penalties (may)* include
imprisonment, nes and denial of insurance benets.
*Applies in ME Only.
Applicable in NJ Any person who includes any false or
misleading information on an application for an insurance
policy is subject to criminal and civil penalties.
Applicable in OR Any person who knowingly and with
intent to defraud or solicit another to defraud the insurer by
submitting an application containing a false statement as to
any material fact may be violating state law.
COVERAGE EXCLUSIONS
The following exclusions are contained in the commercial general liability coverage provided by this program:
Abuse, molestation, harassment or sexual conduct; Aircraft/hot air balloon; Airport; (the ownership, operation,
maintenance, or use of any aireld or airport facility or premises. This exclusion does not apply to concessionaires,
exhibitors, or vendors selling, displaying, demonstrating or promoting their products or services at any aireld or airport
facility or premises); Amusement devices(the ownership, operation, maintenance or use of: any mechanical or non-
mechanical ride, slide, water slide, any inatable recreation device, any bungee operation or equipment, any vertical
device or equipment use for climbing- either permanently afxed or temporarily erected, or dunk tank. Amusement
device does not include any video arcade or computer games or structures that are not designed to bounce on, slide
on, ride on or tunnel through); Animals (injury or death to any animal, or injury, death or property damage caused by
an animal owned, rented or hired by you); Asbestos, Commercial general liability standard exclusions (CG 0001 04/13
edition); Employment-related practices; Fireworks; Fungi or bacteria; Lead; Nuclear energy liability; Performers; Rodeos;
Saddle animal; Snowmobile; Violation of statues that govern emails, faxes, phone calls or other methods of sending
materials or information; Those operations listed as ineligible: Alcoholic beverages - selling or furnishing; Animals, Auto
parts (mechanical); Body piercing or permanent tattooing; Christmas tree retail lots, Contractors (lighting, stage, sound,
etc.); Cryogenic chambers/therapy; E-commerce selling; Fire safety equipment; Fireworks sales and displays, Haunted
attractions; Hot wax impressions; Leasing/rental operations; Mazes (corn/hay/fence); Medical testing; Motorsports
activities; Nutritional or health supplement products (selling); On-site installations, service or repair of products; On-
site equipment sales and rental; Oxygen or aromatherapy bars; Paintball equipment/accessories; Photographers
(unless for single event home-based photographer); Protective equipment or apparel; Storefront operations; Tobacco
products (including e-cigarettes/vapor products); Toys (for ages 4 and under); Unmanned aircraft systems (e.g.: drones,
RC aircraft); Vehicles in motion; Watercraft exhibits on water; Weapon sales; Weight loss plans or products (selling);
Wholesale business operations.
Page 5 of 7
1629 5/18
IMPORTANT INFORMATION. PLEASE READ AND SIGN.
Electronic Signature Disclosure and Consent
The Electronic Signatures in Global and National Commerce Act (15 U.S.C. § 7001, et seq.) provides that a signature, contract or other record may
not be denied legal effect, validity or enforceability solely because it is in electronic form or because an electronic signature was used in a transaction.
K&K Insurance Group (K&K), whether on its own behalf, and/or on behalf of an insurer and/or third parties, may utilize the internet, email, cloud
services, digital storage, digital media or similar electronic means to transmit Policy Documents to its clients. This Agreement informs you of your
rights when we are delivering and you are receiving such documents from us electronically.
By agreeing to proceed with this transaction, you acknowledge and consent to the following:
1. I hereby voluntarily consent to proceeding with this transaction, and all subsequent actions related to this transaction, electronically.
2. I understand that further documents relating to this insurance purchased through K&K, including but not limited to correspondence,
communications,conrmations,requestsforpremiumpaymentsandpolicydocuments,may,totheextentpermittedbylaw,betransmittedby
electronic means to me, including by e-mail sent to the e-mail address I have provided as part of this transaction and/or my on-line registration. I
consent to such documents being provided to me electronically.
3. Notwithstanding paragraph 2, any notice of cancellation shall be sent to me by mailing to the address I have provided as part of my registration
and/or application for insurance, or to such other address for which I have provided notice pursuant to the terms of the policy.
4. Any change or revision to the e-mail address or other electronic contact information which I have provided as part of this transaction and/or my
on-line registration process shall be requested by me by logging onto this website, or by mailing a written notice to: K&K Insurance;
1712MagnavoxWay;FortWayne,IN46804.
5. I understand that I have the right to obtain a paper copy of any electronic record provided to me pursuant to this transaction or any
subsequent transaction involving my coverage by mailing a written request to the address provided in paragraph 4.
6.Inordertoaccesstheelectronicrecordsprovided,thefollowinghardwareandsoftwarearerequired:(a)apersonalcomputerorother
device through which Internet access is available, (b) an Internet connection, (c) an e-mail account with an Internet service provider, and (d)
Adobe Acrobat Reader.
7. I understand that I have the right and option to withdraw my consent to the receipt of further electronic documents at any time, by mailing
a written request to the address provided in paragraph 4. By withdrawing my consent to electronic delivery of documents I understand that I
will receive a paper copy of future policy documentation.
8.Informationrelatingtothistransactionissubjecttothetermsofourprivacystatement,acopyofwhichisprovidedatwww.kandkinsurance.com.
9.DOCUMENTDELIVERY.Afterthisenrollmentformisapproved,youwillreceiveacerticateofinsuranceshowingevidencethatcoverage
hasbeenbound.Whensubmittedthroughaninsuranceagentorbroker,thiscoveragedocumentwillonlybedeliveretothem.Additional
certicaterequestswillbeissuedtothesameperson.Pleaseselectonlyoneoption.
m E-mail to: __________________________________________ attn: _________________________________________
(selectingthisoptionconrmsyouremaildeliveryofdocuments.SeeElectronicConsentsectionofenrollmentform)
mFaxto: __________________________________________ attn:_________________________________________
m Mail to: __________________________________________ attn: _________________________________________
__________________________________________
Warranty, Compensation & Electronic Disclosure and Consent
PLEASE READ, COMPLETE #9 BELOW, AND SIGN ON PAGE 6
IMPORTANT INFORMATION. PLEASE READ AND SIGN.
Warranty and Disclosure Statement: I understand that the insurance company, in determining whether to provide insurance coverage, will rely
ontheinformationcontainedinthisformandallotherinformationbeingsubmitted.Iherebywarrant,representandconrmthat,tothebestofmy
knowledge, all information provided is complete, true and correct.
Iamawarethattheinsurancecompanyexpectsaccuratereportingformypremiumcalculation,andshouldmyguresexceedmyestimatesduring
thecoveragetermIwillmakearrangementstopaytheadditionalpremium.Iunderstandthatmybookandrecordsmaybeexaminedorauditedby
the insurance company at any time during the coverage period and up to three years thereafter. Intentional misrepresentation or misreporting may
jeopardizecoverage.K&Kreservestherighttodecline/voidanyineligiblecoverage.
Ifurtheracknowledgethat,Ihavereviewedallinformationprovidedwiththisenrollmentformandunderstandtheexclusionswhichapply,aswellas
the activities and operations for which coverage is not provided.
Compensation and Other Disclosure Information: K&K Insurance Group, Inc. (“K&K”) is an insurance producer licensed in your state. Insurance
producersareauthorizedbytheirlicensetoconferwithinsurancepurchasersaboutthebenets,termsandconditionsofinsurancecontracts;to
offeradviceconcerningthesubstantivebenetsofparticularinsurancecontracts;tosellinsurance;andtoobtaininsuranceforpurchasers.The
role of the producer in any particular transaction involves one or more of these activities. Compensation will be paid to the producer, based on the
insurance contract the producer sells. Depending on the insurer(s) and insurance contract(s) the purchaser selects, compensation will be paid by
the insurer(s) selling the insurance contract or by another third party. Such compensation may vary depending on a number of factors, including
the insurance contract(s) and the insurer(s) the purchaser selects. In addition, K&K may charge a fee for administrative services. Your signature
on your application, quote form, check, credit card and/or other authorization for payment of your premium, will be deemed to signify your consent
to and acceptance of the terms and conditions including the compensation, as disclosed above, that is to be received by K&K. The insurance
purchasermayobtaininformationaboutcompensationexpectedtobereceivedbytheproducerbasedinwholeorinpartonthesaleofinsurance
tothepurchaser,andcompensationexpectedtobereceivedbasedinwholeorinpartofanyalternativequotespresentedtothepurchaserbythe
producer, by emailing a written request to warranty@kandkinsurance.com.
In addition, premiums paid by clients to K&K for remittance to insurers, client refunds and claim payments paid to K&K by insurance companies for
remittancetoclientsaredepositedintoduciaryaccountsinaccordancewithapplicableinsurancelawsuntiltheyareduetobepaidtotheinsurance
companyorClient.Subjecttosuchlawsandtheapplicableinsurancecompany’sconsent,whererequired,K&Kwillretaintheinterestorinvestment
income earned while such funds are on deposit in such accounts.
Inplacing,renewing,consultingonorservicingyourinsurancecoveragesK&Kanditsafliatesmayparticipateincontingentcommission
arrangementswithinsurancecompaniesthatprovideforadditionalcontingentcompensation,if,forexample,certainunderwriting,protability,
volume or retention goals are achieved. Such goals are typically based on the total amount of certain insurance coverages placed by K&K with the
insurance company or the overall performance of the policies placed with that insurance company, not on an individual policy basis. As a result,
K&Kmaybeconsideredtohaveanincentivetoplaceyourinsurancecoverageswithaparticularinsurancecompany.WhereK&Kparticipatesin
contingent commission arrangements with insurance companies, K&K may be entitled to additional commission in the range of 0 to 5% depending
uponwhetherandwhenspeciedthresholdsareachieved.
Ourliabilitytoyou,intotal,forthedurationofourbusinessrelationshipforanyandalldamages,costs,andexpenses(includingbutnotlimitedto
attorneys’fees),whetherbasedoncontract,tort(includingnegligence),orotherwise,inconnectionwithorrelatedtoourservices(includingafailure
to provide a service) that we provide in total shall be limited to the lesser of $2,500,000 or the singular annual limit of the policy of insurance procured
by us on your behalf from which your damages arise.
Thisliabilitylimitationappliestoyou,ourclient,andextendstoourclient’sparent(s),afliates,subsidiaries,andtheirrespectivedirectors,ofcers,
employees and agents (each a “Client Group Member” of the “Client Group”) wherever located that seek to assert claims against K&K, and its
parent(s),afliates,subsidiariesandtheirrespectivedirectors,ofcers,employeesandagents(eachan“K&KGroupMember”ofthe“K&KGroup”).
Nothing in this liability limitation section implies that any K&K Group Member owes or accepts any duty or responsibility to any Client Group Member.
IfyouoranyofyourGroupMembersassertsanyclaimsormakesanydemandsagainstusoranyK&KGroupMemberforatotalamountinexcess
ofthisliabilitylimitation,thenyouagreetoindemnifyK&Kforanyandallliabilities,costs,damagesandexpenses,includingattorneys’fees,incurred
byK&KoranyK&KGroupMemberthatexceedsthisliabilitylimitation.
AonCorporation,ourultimateparentcompany,anditsafliateshavefromtimetotimesponsoredandinvestedininsuranceandreinsurance
companies.Whilewegenerallyundertakesuchactivitieswithaviewtocreatinganorderlyowofcapacityforourclients,wealsoseekan
appropriate return on our investment. These investments, for which Aon is generally at-risk for potential price loss, typically are small and range from
xed-incometocommonstocktransactions.Insuchcase,thegainsorlosseswemakethroughyourinvestmentscouldpotentiallybelinked,inpart,
to the results of treaties or policies transacted with you. Please visit the Aon website at http://www.aon.com/market_relationships for a current listing
ofinsuranceandreinsurancecarriersinwhichAonCorporateanditsafliatesholdanyownershipinterest.
Applicant or agent signature:__________________________________ Date: ____________________________________________________
Printed name:__________________________________________Title: _________________________________________________________
If an agent: Check here to acknowledge you are signing on behalf of the named insured. m
Applicant Business Name (from page 3): _________________________________________________________________________________
Page 6 of 7
1629 5/18
Copyright © 2018 K&K Insurance Group, Inc. All Rights Reserved.
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Submit a completed enrollment (including signed Warranty Statement) and payment to:
Applicant business name: _____________________________________ Effective date: ________________________
PAY BY ACH (Bank Account):
• E-mail info@eventinsurance-kk.com
or
• Fax 1-260-459-5502
I (we) authorize K&K Insurance Group to initiate a single electronic debit from the account shown below:
Name on Bank Account: ________________________ Bank Name: _______________________________
Draft Amount : $_______________________________ m Checking, or m Savings
Bank Account Routing/Transit Number*_____________ Bank Account Number* ______________________
*See below for an explanation of where to locate these two sets of numbers on your bank check.
________________________________________________________________ Date: ___________________
Authorized Signature(s)/Not required if authorization by phone
________________________________________________________________ Date: ___________________
Authorized Signature(s)/Not required if authorization by phone
PAY BY CHECK: (Payable to K&K Insurance Group)
• Mail Regular Mail Overnight Mail
K&K Insurance K&K Insurance
Event RPG Program Event RPG Program
P.O. Box 2338 1712 Magnavox Way
Fort Wayne, IN 46801-2338 Fort Wayne, IN 46804
PAY BY CREDIT CARD:
• Fax only 1-260-459-5502
m VISA m MASTERCARD m DISCOVER m AMERICAN EXPRESS
Card number: ______________________________________________________________________________
CSC # (card security) code: _________________________________ Expiration date: ____________________
I authorize K&K Insurance Group, Inc. to charge my payment to my credit card in the amount of $ ____________
Print name (as on card): ______________________________________________________________________
Cardholder signature: ________________________________________________________________________
Cardholder phone number: (____)__________________________________
FATCA Notice: Please go to Aon.com/FATCA to obtain appropriate W-9.
PAYMENT OPTIONS
1. Bank Routing/Transit Number - This is a nine digit
number separated by a bar and a colon |: 123456789 |:
2. Account Number - This number may appear as the second,
rst or third series of numbers. Please read carefully.
3. Check Number - Matches number in the upper right corner
of check. NOT REQUIRED FOR ACH.
EXPLANATION OF CHECK NUMBERS
1.
2.
3.
Page 7 of 7
1629 5/18
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Completed 21 July 2020

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