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` ֈ 9z v z T { D G{ ' 9z 9z 9z X 9z 9z 9z ג n} n} n} n} DC ^O ! ^O ` ` ` ` ` ` 60 Cutter Mill Road ( Suite 414
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AMATEUR SPORTS SPECIAL EVENTS APPLICATION COVER SHEET
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.
Amateur Sports Special Event 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 A n n u a l G r o s s R e v e n u e s : $ F O R M T E X T M o n t h s o f O p e r a t i o n : 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 / S p o r 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 a n d c o u r s e m a p , 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 h l e t i c P a r t i c i p a n t s : F O R M T E X T N u m b e r o f A t h l e t i c P a r t i c i p a n t 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 P a r t i c i p a n t A g e R a n g e : F O R M T E X T W i l l i n v i t e d / p r o f e s s i o n a l A t h l e t e s b e p a r t i c i p a t i n g ? 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 R e v e n u e G e n e r a t e d : E n t r y F e e s $ F O R M T E X T A d m i s s i o n F e 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 W h a t c o n t r o l s a r e i n p l a c e t o p r e v e n t u n d e r a g e d r i n k i n g o r o v e r - c o n s u m p t i o n ? F O R M T E X T
4 . S e a t i n g C a p a c i t y : F O R M T E X T E s t i m a t e d T o t a l A t t e n d a n c e : 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 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 , w h o p r o v i d e s t r a f f i c c o n t r o l o n t h e c o u r s e ? 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 S w i m m i n g : A r e c e r t i f i e d l i f e g u a r d s o n d u 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 A r e t h e y C P R t r a i n 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 A r e c e r t i f i c a t e s r e c e i v e d b y I n s u 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 Applicants Statement and Declarations
The applicant declares to the best of his / her knowledge the information contained in this application and all supplements attached to be true and 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.
Fraud NoticeNOTICE 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.
NOTICE TO KENTUCKY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME.
NOTICE TO MINNESOTA AND OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.
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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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