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| Viewing file: Select action/file-type: ࡱ > - / ( ) * + , %` bjbj { ̟ ̟ # X X X X X X X $ T s s s P js d s | _ Vv z { " { { { | O} L } ( B D D D D D D } h D X t | | t t D X X { { t X X { X { B t B r ^ X X b { Jv w9 s ̂ " v / 0 _ 0 2 b b X v } ~ } c } } } D D H X } } } _ t t t t DC 6O # 6O | X X X X X X 60 Cutter Mill Road ( Suite 414
Great Neck, NY 11021
516-466-4200 ( HYPERLINK "http://www.butwin.com" www.butwin.com
fax 516-466-4213 no cover page needed
or exit, save and e-mail to allstate@butwin.com
SPECIAL EVENTS APPLICATION COVER SHEET
Press TAB to move between fields
Agent FORMTEXT F O R M T E X T C o n t a c t F O R M T E X T F O R M T E X T E - m a i l F O R M T E X T F O R M T E X T F O R M T E X T P h o n e F O R M T E X T F O R M T E X T F O R M T E X T F a x F O R M T E X T C o v e r a g e E f f e c t i v e D a t e F O R M T E X T F O R M T E X T FORMTEXT
Please complete the attached Special Events application.
Special Event Supplemental Application
PIIC Producer:Butwin Insurance Group516-466-4200info@butwin.comSubmission Requirements1. FORMCHECKBOX Currently valued, carrier-generated Loss Runs for the current year and the last three years (for accounts where premium exceeds $5,000).2. FORMCHECKBOX Copy of rental agreement or contract to rent or use venue.Account InformationApplicant Name: FORMTEXT A d d r e s s : F O R M T E X T W e b S i t e : w w w . F O R M T E X T E - M a i l A d d r e s s : F O R M T E X T C o n t a c t P e r s o n ( B i l l i n g ) : F O R M T E X T P h o n e : F O R M T E X T C o n t a c t P e r s o n ( L o s s C o n t r o l ) : F O R M T E X T P h o n e : F O R M T E X T E f f e c t i v e D a t e s R e q u e s t e d : F O R M T E X T E v e n t G r o s s R e v e n u e s : $ F O R M T E X T F o r P r o f i t : F O R M C H E C K B O X I n d i v i d u a l F O R M C H E C K B O X P a r t n e r s h i p F O R M C H E C K B O X C o r p o r a t i o n F O R M C H E C K B O X A s s o c i a t i o n F O R M C H E C K B O X O t h e r : F O R M T E X T N o n - P r o f i t : F O R M C H E C K B O X Y e a r s t h i s e n t i t y i n b u s i n e s s : F O R M T E X T Y e a r s e x p e r i e n c e o f t h i s o w n e r : F O R M T E X T H a s t h e a p p l i c a n t h a d a n y c l a i m s f i l e d a g a i n s t i t i n t h e l a s t f o u r y e a r s ? Y e s F O R M C H E C K B O X N o F O R M C H E C K B O X I f y e s , p l e a s e p r o v i d e d e t a i l s : F O R M T E X T 1 . D e s c r i p t i o n o f E v e n t : F O R M T E X T 2 . D a t e s : F O R M T E X T F O R M T E X T F O R M T E X T T i m e s : F O R M T E X T F O R M T E X T F O R M T E X T ( A t t a c h b r o c h u r e o r p r o m o t i o n a l m a t e r i a l s i f a p p l i c a b l e . ) T o t a l N u m b e r o f A t t e n d e e s : F O R M T E X T N u m b e r o f A t t e n d e e s p e r d a y : F O R M T E X T T o t a l N u m b e r o f V o l u n t e e r s : F O R M T E X T N u m b e r o f V o l u n t e e r s p e r d a y : F O R M T E X T R e v e n u e G e n e r a t e d : A d m i s s i o n F e e s $ F O R M T E X T L i q u o r S a l e s $ F O R M T E X T F o o d S a l e s $ F O R M T E X T M e r c h a n d i s e $ F O R M T E X T 3 . I s a l c o h o l b e i n g s e r v e d ? Y e s F O R M C H E C K B O X N o F O R M C H E C K B O X B y w h o m ? F O R M T E X T H a s s e r v e r p r o v i d e d e v i d e n c e o f l i q u o r l i a b i l i t y i n s u r a n c e ? Y e s F O R M C H E C K B O X N o F O R M C H E C K B O X I s L i q u o r L i a b i l i t y c o v e r a g e d e s i r e d ? Y e s F O R M C H E C K B O X N o F O R M C H E C K B O X I f Y e s , c o m p l e t e l i q u o r l i a b i l i t y s u p p l e m e n t . F O R M T E X T
4 . N a m e o f V e n u e : F O R M T E X T S e a t i n g C a p a c i t y : F O R M T E X T S e a t i n g T y p e : F O R M D R O P D O W N N u m b e r o f E x h i b i t o r s : F O R M T E X T W h o i s s u p p l y i n g s e c u r i t y a t v e n u e ? F O R M T E X T ( I f p r i v a t e f i r m , t h e y m u s t h a v e i n s u r a n c e a n d n a m e y o u a s a n a d d i t i o n a l i n s u r e d . ) D e s c r i b e t h e s a f e g u a r d s i n p l a c e t o p r e v e n t i n j u r y t o s p e c t a t o r s : F O R M T E X T D e s c r i b e f i r s t a i d / m e d i c a l a r r a n g e m e n t s : F O R M T E X T 5 . I s t h e e v e n t l i m i t e d t o v e n u e g r o u n d s ? Y e s F O R M C H E C K B O X N o F O R M C H E C K B O X I f n o , p r o v i d e d e t a i l s : F O R M T E X T D e s c r i b e f i r s t a i d / m e d i c a l a r r a n g e m e n t s : F O R M T E X T 6 . S w i m m i n g : Y e s F O R M C H E C K BOX No FORMCHECKBOX If Yes, are certified lifeguards on duty?Yes FORMCHECKBOX No FORMCHECKBOX Are they CPR trained?Yes FORMCHECKBOX No FORMCHECKBOX Are certificates received by Insured?Yes FORMCHECKBOX No FORMCHECKBOX 7.Athletic EventsYes FORMCHECKBOX No FORMCHECKBOX If Yes, is athletic participant coverage desired?Yes FORMCHECKBOX No FORMCHECKBOX 8.PerformersYes FORMCHECKBOX No FORMCHECKBOX I f y e s , p l e a s e l i s t a l l p e r f o r m e r s : F O R M T E X T 9 . A r e y o u r e q u i r e d t o p r o v i d e c e r t i f i c a t e s o f i n s u r a n c e t o a n y o t h e r e n t i t y ? Y e s F O R M C H E C K B O X N o F O R M C H E C K B O X I f y e s , p l e a s e p r o v i d e n a m e s o f c e r t i f i c a t e h o l d e r s a n d t h e i r i n t e r e s t : F O R M T E X T 1 0 . O t h e r C o m m e n t s F O R M T E X T A p p l i c a n t s S t a t e m e n t a n d D e c l a r a t i o n s
T h e a p p l i c a n t d e c l a r e s t o t h e b e s t o f h i s / h e r k n o w l e d g e t h e i n f o r m a t i o n c o n t a i n e d i n t h i s a p p l i c a t i o n a n d a l l s u p p l e m e n t s a t t a c h e d t o b e t r u e a n d that no material facts have been suppressed or misstated. The applicant further understands that any false or fraudulent statements or misrepresentations could result in termination or voidance of any insurance contract issued from the information stated herein.Applicants SignatureDateBroker/Agents SignatureDate
Fraud Notice
NOTICE TO APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATENMENT 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 MAY SUJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
NOTICE TO NEW YORK APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES 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 SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
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N O T I C E T O N E B R A S K A A N D O K L A H O M A A P P L I C A N T S : A N Y P E R S O N W H O K N O W I N G L Y A N D W I T H I N T E N T T O I N J U R E , D E F R A U D O R D E C E I V E A N Y I N S U R E R , M A K E S A N Y C L A I M F O R T H E P R O C E E D S O F A N I N S U R A N C E P O L I C Y C O N T A I N I N G A N Y F A L S E , I N C O M P L E T E O R M I S L E A D I N G I N F O R M A T I O N I S G U I L T Y O F A F E L O N Y .
N O T I C E T O P E N N S Y L V A N I A A P P L I C A N T S : A N Y P E R S O N W H O K N O W I N G L Y A N D W I T H I N T E N T T O D E F R A U D A N Y I N S U R A N C E C O M P A N Y O R O T H E R P E R S O N F I L E S A N A P P L I C A T I O N F O R I N S U R A N C E O R S T A T E M E N T O F C L A I M C O N T A I N I N G A N Y M A T E R I A L L Y F A L S E I N F O R M A T I O N O R C O N C E A L S F O R T H E P U R P O S E O F M I S L E A D I N G I N F O R M A T I O N C O N C E R N I N G A N Y F A C T M A T E R I A L T H E R E T O C O M M I T S A F R A U D U L E N T I N S U R A N C E A C T W H I C H I S A C R I M E A N D S U B J E C T S S U C H P E R S O N T O C R I M I N A L A N D C I V I L P E N A L T I E S .
N O T I C E T O F L O R I D A A P P L I C A N T S : A N Y P E R S O N W H O , K N O W I N G L Y N D W I T H I N T E N T T O I N J U R E , D E F R A U D , O R D E C E I V E A N Y I N S U R E R F I L E S A S T A T E M E N T O F C L A I M O R A N A P P L I C A T I O N C O N T A I N I N G A N Y F A L S E , I N C O M P L E T E O R M I S L E A D I N G I N F O R M A T I O N I S G U I L T Y O F A F E L O N Y O F T H E T H I R D D E G R E E .
N O T I C E T O N E W J E R S E Y A P P L I C A N T S : A N Y P E R S O N W H O I N C L U D E S A N Y F A L S E O R M I S L E A D I N G I N F O R M A T I O N O N A N A P P L I C A T I O N F O R A N I N S U R A N C E P O L I C Y I S S U B J E C T T O C R I M I N A L A N D C I V I L P E N A L T I E S .
N O T I C E T O M A I N E A N D V I R G I N I A A P P L I C A N T S : I T I S A C R I M E T O K N O W I N G L Y P R O V I D E F A L S E , I N C O M P L E T E O R M I S L E A D I N G I N F O R M A T I O N T O A N I N S U R A N C E C O M P A N Y F O R T H E P U R P O S E O F D E F R A U D I N G T H E C O M P A N Y . P E N A L T I E S I N C L U D E I M P R I S O N M E N T , F I N E S A N D D E N I A L O F I N S U R A N C E B E N E F I T S .
N O T I C E T O O R E G O N A P P L I C A N T S : A N Y P E R S O N W H O K N O W I N G L Y A N D W I T H I N T E N T T O D E F R A U D O R S O L I C I T A N O T H E R T O D E F R A U D A N I N S U R E R : ( 1 ) B Y S U B M I T T I N G A N A P P L I C A T I O N , O R ( 2 ) B Y F I L I N G A C L A I M C O N T A I N I N G A F A L S E S T A T E M E N T A S T O A N Y M A T E R I A L F A C T , M A Y B E V I O L A T I N G S T A T E L A W .
N O T I C E T O D I S T R I C T O F C O L U M B I A A P P L I C A N T S : " W A R N I N G : I T I S A C R I M E T O P R O V I D E F A L S E O R M I S L E A D I N G I N F O R M A T I O N T O A N I N S U R E R F O R T H E P U R P O S E O F D E F R A U D I N G T H E I N S U R E R O R A N Y O T H E R P E R S O N . P E N A L T I E S I N C L U D E I M P R I S O N M E N T A N D / O R F I N E S . I N A D D I T I O N , A N I N S U R E R M A Y D E N Y I N S U R A N C E B E N E F I T S I F F A L S E I N F O R M A T I O N M A T E R I A L L Y R E L A T E D T O A C L A I M W A S P R O V I D E D B Y T H E A P P L I C A N T . "
N O T I C E T O N E W M E X I C O A P P L I C A N T S : " A N Y P E R S O N W H O K N O W I N G L Y P R E S E N T S A F A L S E O R F R A U D U L E N T C L A I M F O R P A Y M E N T O F A L O S S O R B E N E F I T O R K N O W I N G L Y P R E S E N T S F A L S E I N F O R M A T I O N I N A N A P P L I C A T I O N F O R I N S U R A N C E I S G U I L T Y O F A C R I M E A N D M A Y B E S U B J E C T T O C I V I L F I N E S A N D C R I M I N A L P E N A L T I E S . "
N O T I C E T O T E N N E S S E E A P P L I C A N T S : " I T I S A C R I M E T O K N O W I N G L Y P R O V I D E F A L S E , I N C O M P L E T E O R M I S L E A D I N G I N F O R M A T I O N T O A N I N S U R A N C E C O M P A N Y F O R T H E P U R P O S E O F D E F R A U D I N G T H E C O M P A N Y . P E N A L T I E S I N C L U D E I M P R I S O N M E N T , F I N E S A N D D E N I A L O F I N S U R A N C E B E N E F I T S . " A p p l i c a n t s S i g n a t u r e D a t e B r o k e r / A g e n t s S i g n a t u r e D a t e
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