Form Spapp - Application For Special Events-Liquor Liability Insurance
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1
2
3APPLICATION FOR SPECIAL EVENTS-LIQUOR LIABILITY INSURANCE
CENTREX LIQUOR LIABILITY PROGRAM
Surplus Lines Producer:
___________________________________
1.
Type of Application:
City/State:
___________________________________
New
Renewal Expiring Policy #: ______________________
Contact:
___________________________________
All questions must be answered fully. Incomplete or inaccurate answers will cause delay in processing and may cause coverage to be declined or rescinded after issuance.
Use “NONE” or “N/A” where applicable. Attach brochure/flyer if available. APPLICATION MUST BE COMPLETED, SIGNED AND DATED BY A PRINCIPAL OF THE FIRM
OR ENTITY APPLYING FOR COVERAGE.
2.
Dates of Event
From: _________________________
To: _____________________________
Hours of Event Each Day:
Day
From
To
3.
Limits Requested:
$50,000
$100,000
$200,000
$300,000
$500,000
$1,000,000
4.
Name of Applicant (show all names including legal and dba’s): ______________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
Applicant’s Mailing Address (city, state and zip):
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
Event Name (if applicable):__________________________________________________________________________________________________________
Event Site Address: _______________________________________________________________ Telephone #: (
) __________________________
5.
Form of business:
Individual
Joint Venture
Partnership
Corporation
Limited Liability Company
Other: ___________________________________
____________________________________________________________________________________________
6.
*Description of Event including age of crowd,
____________________________________________________________________________________________
type of crowd & any unusual exposure (e.g.
____________________________________________________________________________________________
races, mechanical rides, etc.)
____________________________________________________________________________________________
*INCLUDE A COPY OF THE EVENT
____________________________________________________________________________________________
BROCHURE/FLYER , IF AVAILABLE.
____________________________________________________________________________________________
# of Years Event Held
__________
7.
Describe Entertainment
_____________________________________________________________________________________________
_____________________________________________________________________________________________
If live musical entertainment, describe type of music:
Top 40
Classic Rock & Roll
Soft Rock
Jazz
R&B
Rap
Alternative
Disco
Country/Western
Other; describe: _____________________________
8.
Does Applicant allow dancing?
Yes
No
If yes,
Size of dance floor:____________________ square feet
9.
Type of Alcohol served & price per drink
Beer/Ale
$___________
If alcohol is not sold by the drink, explain below:
Wine
$___________
_______________________________________
Liquor
$___________
_______________________________________
_______________________________________
Does Applicant allow BYOB (Bring Your Own Bottle)?
Yes
No
10. Estimated Total Attendance at this event
____________
11. Provide Applicant’s sales, AT THIS EVENT, for food and all alcoholic beverages (liquor, beer, and wine) below:
Alcohol
Food
Other
Total
$
$
$
$
12. Liquor License Required?
Yes
No
Does the applicant have a Liquor License?
Yes
No
13. Does Applicant check ID’s?
Yes
No
FORM #SPAPP(10/03)
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Parent category: Legal