(Please indicate the % of gross sales/receipts by type of operation (total of all services should equal 100%)
The statements and answers herein are warranted to be true and are made with the knowledge that the Company will act in reliance upon them. This request is designed to solicit information and is not a policy or policy binder on the part of the Applicant, its agency, or the Insurance Company. Any misrepresentations by the Applicant may result in denial of coverage or the cancellation of any subsequently issued policy or policies. Since this is a member benefit, you may be contacted by the ESA for membership.