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Special Events Liability Application

LIONS CLUB / DISTRICT
SPECIAL EVENT SUPPLEMENTAL APPLICATION

All fields are required. Use N/A if not applicable.

ACCOUNT INFORMATION

Lions Club/District:
Address: Address Cont:
City: State: Zipcode:
Web site: http:// E-mail Address:
Contact person: Phone:
Effective dates requested:
Event gross revenue: $

Limits Requested: $1,000,000 each occurrence /$3,000,000 aggregate
Other:
Would you like one policy to cover multiple events? Yes No

1. Has the Club / District had any claims filed against it in the last four (4) years? Yes No
If yes, please provide details:
 
2. Description of events :
 
3. Date(s):
Times:
(Please forward promotional materials by mail or fax if applicable.)
Total number of attendees: Number of attendees per day:
Total number of volunteers: Number or volunteers per day:
Revenue generated : Admission fees $
  Liquors sales $
  Food sales $
  Merchandise $
 
4. Is alcohol being served? Yes No
If yes, by whom?
Has server provided evidence of liquor liability insurance? Yes No
Is Liquor Liability coverage desired? Yes No
If yes, complete Liquor Liability supplement.
 
5. Name of venue:
Address of venue:
Seating capacity:
Seating type: (permanent grandstands, temporary bleacher)
Number of exhibitors:
Who is providing security at venue?
If private firm, they must have insurance and name you as an Additional Insured.
Describe the safeguards in place to prevent injury to spectators:
Describe first aid/medical arrangements:
 
6. Is the event limited to venue grounds? Yes No
If no, provide details:
Describe first aid / medical arrangements
 
7. Swimming: Yes No
If yes, are certified lifeguards on duty? Yes No
Are all swimming pools and spas compliant with Virginia Graeme Baker pool and Spa Safety Act? If no, provide time table and action plan. Yes No
Are they CPR trained? Yes No
Are certificates received by insured? Yes No
 
8. Is the Applicant required to provide certificates of insurance to any other entity? Yes No
If yes, please provide names of certificate holders and their interest:
 
9. Does certificate holder need to be included as an additional insured? Yes No
 
10. Other comments:

You must agree to the Fraud Notice Statements

The Undersigned warrants that to the best of his/her knowledge and belief the statements set forth herein are true. The Undersigned further declares that any occurrence or event that takes place prior to the effective date of the insurance applied for which may render inaccurate, untrue, or incomplete any statement made will immediately be reported in writing to the Underwriter. The Underwriter may withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance. The Underwriter is hereby authorized to make any investigation and inquiry in connection with the information, statements and disclosures provided in this Application. The signing of this Application does not bind the Undersigned to purchase the insurance, nor does the review of this Application bind the insurance company to issue a policy. It is agreed that this Application shall be the basis of the contract should a policy be issued. This Application will be attached and become a part of the policy.


Name
Title		 (MUST BE SIGNED BY THE CLUB PRESIDENT, SECRETARY OR TREASURER / DISTRICT GOVERNOR, SECRETARY OR TREASURER FOR DISTRICT)

Date
Authorized Signature (if submitting paper copy)
The above signed warrants that he/she is authorized and has the power to complete and execute this Application, including the Warranty Statement on behalf of the Applicant and their respective Directors, Officers or other insured persons.

   


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