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B ` ` ` ` ` ` u 60 Cutter Mill Road ( Suite 414
Great Neck, NY 11021
516-466-4200 ( HYPERLINK "http://www.butwin.com" www.butwin.com
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SPECIAL EVENT LIQUOR LIABILITY 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.
Special Event Liquor Liability Supplemental Application
PIIC Producer:Butwin Insurance Group516-466-4200info@butwin.comAccount InformationApplicant Name: FORMTEXT A d d r e s s : F O R M T E X T P h o n e N u m b e r : 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 1 . N a m e o f E v e n t : F O R M T E X T D a t e ( s ) o f E v e n t : F O R M T E X T E v e n t H o u r s : F O R M T E X T 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 T o t a l N u m b e r o f P a r t i c i p a n t s : F O R M T E X T R e v e n u e G e n e r a t e d : F O R M T E X T L i q u o r R e v e n u e G e n e r a t e d : F O R M T E X T 2 . I s t h e L i q u o r L i c e n s e i n y o u r n a m 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 f y e s , i s i t a n annual license?Yes FORMCHECKBOX No FORMCHECKBOX 3.Have you ever been assessed a fine or violation of a law concerning the sale, serving or providing of alcohol?Yes FORMCHECKBOX No FORMCHECKBOX If yes, explain: FORMTEXT 4 . H a v e y o u h a d a n y o c c u r r e n c e s t h a t h a v e a r i s e n o u t o f t h e s a l e , s e r v i n g o r p r o v i d i n g o f a n y a l c o h o l i c b e v e r a g 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 f y e s , e x p l a i n : F O R M T E X T 5 . H a s y o u r l i q u o r l i a b i l i t y i n s u r a n c e b e e n c a n c e l e d o r n o n - r e n e w e d i n t h e l a s t 3 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 , e x p l a i n : F O R M T E X T 6 . A r e y o u r e m p l o y e e s o r v o l u n t e e r s s e r v i n g l i q u o r ? 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 i s s e r v i n g ? F O R M T E X T a n d d o y o u s e c u r e C e r t i f i c a t e o f I n s u r a n c e f r o m t h e c o n t r a c t i n g p a r 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 7 . A r e s e r v e r s , b a r t e n d e r s a n d p a r k i n g v a l e t s r e q u i r e d t o p a r t i c i p a t e i n a l c o h o l a w a r e n e s s p r o g r a m s ? Y e s F O R MCHECKBOX No FORMCHECKBOX 8.Is there a Designated Driver Program or escort service provided for those unable to drive?Yes FORMCHECKBOX No FORMCHECKBOX 9.Is there a limit placed on the quantity of alcoholic beverages purchased at one time?Yes FORMCHECKBOX No FORMCHECKBOX Explain: FORMTEXT 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 t h a t n o m a t e r i a l f a c t s h a v e b e e n s u p p r e s s e d o r m i s s t a t e d . T h e 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 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.
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. NOTICE TO NEBRASKA AND OKLAHOMA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY.
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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 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 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 . "
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