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P I I C P r o d u c e r : F O R M T E X T B u t w i n I n s u r a n c e G r o u p B r o k e r : F O R M T E X T S u b m i s s i o n R e q u i r e m e n t s 1 . F O R M C H E C K B O X C u r r e n t l y v a l u e d , c a r r i e r - g e n e r a t e d L o s s R u n s f o r t h e c u r r e n t y e a r a n d t h e l a s t t h r e e y e a r s ( f o r a c c o u n t s w h e r e p r e m i u m e x c e e d s $ 5 , 0 0 0 ) . 2 . F O R M C H E C K B O X C o p y o f r e n t a l a g r e e m e n t o r c o n t r a c t t o r e n t o r u s e v e n u e . A c c o u n t I n f o r m a t i o n A p p l i c a n t N a m e : F O R M T E X T 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 Has server provided evidence of liquor liability insurance?Yes FORMCHECKBOX No FORMCHECKBOX Is Liquor Liability coverage desired?Yes FORMCHECKBOX No FORMCHECKBOX If Yes, complete liquor liability supplement. FORMTEXT
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 B O X N o F O R M C H E C K B O X I f Y e s , a r e c e r t i f i e d l i f e g u a r d s o n 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 If yes, please list all performers: FORMTEXT 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 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 ed. 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.
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 C Z \ x z | 0 2 8 : V X Z \ ^ p
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N O T I C E T O M I N N E S O T A A N D O H I O A P P L I C A N T S : A N Y P E R S O N W H O , W I T H I N T E N T T O D E F R A U D O R K N O W I N G T H A T H E / S H E I S F A C I L I T A T I N G A F R A U D A G A I N S T A N I N S U R E R , S U B M I T S A N A P P L I C A T I O N O R F I L E S A C L A I M C O N T A I N I N G A F A L S E O R D E C E P T I V E S T A T E M E N T I S G U I L T Y O F I N S U R A N C E F R A U D .
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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