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ARTICLES APPLICATION CATERERS AND HALLS GENERAL LIABILITY AND (Colonial General Insurance Agency, Inc)

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GLS-APP-21s (3-18) Page 1 of 8
Scottsdale Insurance Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Indemnity Company
Home Office: One Nationwide Plaza
Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale Surplus Lines Insurance Company
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
CATERERS AND HALLS GENERAL LIABILITY AND MISCELLANEOUS
ARTICLES APPLICATION
Applicant’s Name:
Mailing Address:
Location Address:
Agency Name:
Agent No.:
Address:
E-mail:
Phone No.:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
Applicant is: Individual Corporation Partnership Joint Venture Limited Liability Company
Other (Specify):
Website Address:
E-mail Address: Phone No.:
Inspection Contact: Phone No.:
E-mail Address:
Limits Of Liability and Deductible Requested:
General Aggregate (other than Products/Completed Operations) $
Products and Completed Operations Aggregate $
Personal and Advertising Injury (any one person or organization) $
Each Occurrence $
Damage To Premises Rented To You (any one premise) $
Medical Expense (any one person) $
Other Coverages, Restrictions, and/or Endorsements:
$
Deductible $
GLS-APP-21s (3-18) Page 2 of 8
Miscellaneous Articles:
Miscellaneous Articles Coverage and Deductible
$ 2,500/$250 deductible (included)
$ 5,000/$250 deductible
$ 7,500/$250 deductible
$10,000/$250 deductible
$15,000/$250 deductible
$25,000/$250 deductible
1. Description of operations:
2. Number of years in business: ..................................................................................................................
3. Is applicant a booking agent or an event/party planner? ...................................................................... Yes No
4. Payroll: Food receipts:
Number of Employees: Liquor receipts:
Miscellaneous receipts:
5. Give percentage of operations for the following:
Airline industry:
% Conventions:
% Meetings:
%
Off
-shore Gas/Oil Rigs:
% Parties:
% Ships:
%
Sporting events:
% Weddings:
% Other—Describe:
%
6. Does applicant have liquor liability? ....................................................................................................... Yes No
If yes, indicate carrier: Limits:
7. Does applicant own or lease (long-term) a hall? .................................................................................... Yes No
If yes:
What is the square footage? ........................................................................................................................
How many acres of land? ............................................................................................................................
8. Does applicant have outdoor venue(s) without hall exposure? ........................................................... Yes No
If yes, how many acres of land? ..................................................................................................................
9. Does applicant have a parking area? ...................................................................................................... Yes No
If yes, is parking area well lit? ...................................................................................................................... Yes No
10. Does applicant’s employees provide valet parking service? ............................................................... Yes No
If yes, is there any off premises valet parking by the applicant’s employees not in conjunction with halls
exposure? ....................................................................................................................................................
Yes No
If yes, explain:
11. Does applicant subcontract valet parking services on hall premises or off premises in conjunc-
tion with catering operations? .................................................................................................................
Yes No
If yes:
Do subcontractors provide certificate of insurance with liability limits equal or greater than our
applicant? ....................................................................................................................................................
Yes No
Do written contracts contain hold harmless agreements in favor of the applicant? .................................... Yes No
Does applicant require all subcontractors to include the applicant as an additional insured on the Gen-
eral Liability and Garage policies? ...............................................................................................................
Yes No
GLS-APP-21s (3-18) Page 3 of 8
12. Does applicant operate a limousine service for guests? ...................................................................... Yes No
If yes, where is Automobile Liability Coverage insured?
13. Does applicant employ security guards? ............................................................................................... Yes No
If yes:
Number of armed security guards: ............. Number of unarmed security guards: .........
Are licensing and employee background checks required? ........................................................................ Yes No
If armed:
Are they certified for use of firearms by the appropriate state agency or firearms certification school? ..... Yes No
14. Does applicant hire security guards? ..................................................................................................... Yes No
If yes:
Are certificates of insurance required from subcontractor? ......................................................................... Yes No
Is applicant included as an additional insured on subcontractor’s policy? .................................................. Yes No
15. Does applicant have Workers’ Compensation coverage in force? ...................................................... Yes No
16. Where is food prepared? Commercial kitchen Other
If other, please provide complete details:
17. Does applicant package and sell food under their own label? ............................................................. Yes No
18. Are health department regulations followed? ........................................................................................ Yes No
19. How are dishes and linens cleaned and sanitized?
20. Describe food storage procedures:
21. Are records kept on food suppliers? ....................................................................................................... Yes No
22. Equipment:
Indicate which of the following are used:
Amusement devices (describe: )
Barricades Portable restrooms
Dance floors Space heaters
Folding chairs/tables Tents
Grills (electric, gas, LPG) (describe: ) Tiki torches/live flames
23 Does applicant have a regularly serviced wet chemical fire suppressant system that covers all
grease cooking appliances, has a hood, grease removal devise and duct system? .........................
Yes No
24. Does applicant separately rent equipment to others? .......................................................................... Yes No
If yes, what are receipts? .............................................................................................................................
25. Does applicant subcontract any operations? ........................................................................................ Yes No
If yes:
a. Description of operations subcontracted:
b. Annual cost of subcontracted work: ......................................................................................................
GLS-APP-21s (3-18) Page 4 of 8
c. Are all subcontractors required to carry General Liability and Workers Compensation Insurance? .... Yes No
If yes, minimum General Liability limits required:..................................................................................
d. Are certificates of insurance required from all subcontractors? ............................................................ Yes No
e. Is applicant included as an additional insured on all subcontractors’ policies? .................................... Yes No
f. Do written contracts contain hold-harmless agreements in favor of the applicant? ............................. Yes No
If no, explain when not required:
26. Additional Insured Information:
Name Address Interest
27. Schedule Of Hazards:
Loc.
No.
Classification Description
Class.
Code
Exposure
Premium Basis
(s) Gross Sales
(p) Payroll
(a) Area
(c) Total Cost
(t) Other
28. During the past three years, has any company canceled, declined or refused similar insurance
to the applicant? (Not applicable to Missouri applicants) ..........................................................................
Yes No
If yes, explain:
29. Does risk engage in the generation of power, other than emergency back-up power, for their
own use or sale to power companies?....................................................................................................
Yes No
If yes, describe:
30. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
31. Prior Carrier Information:
Year:
Year:
Year:
Year:
Year:
Carrier
Policy No.
Coverage
Occurrence or
Claims Made
Total Premium
GLS-APP-21s (3-18) Page 5 of 8
32. Loss History:
Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give
rise to claims for the prior five years.
Check if no losses last five years.
Date of
Loss
Description of Loss
Amount
Paid
Amount
Reserved
Claim Status
(Open or
Closed)
FRAUD WARNING: 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
subjects such person to criminal and civil penalties. (Not applicable in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY,
OH, OK, OR, RI, TN, VA, VT or WA.)
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may
include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance
company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for
the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an
insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addi-
tion, an insurer may deny insurance benefits if false information materially related to a claim was provided by the appli-
cant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insur-
er files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a fel-
ony of the third degree.
NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be pre-
sented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any
agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or state-
ment as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or
commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal
insurance which such person knows to contain materially false information concerning any fact material thereto; or con-
ceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act,
which is a crime and subjects such person to criminal and civil penalties.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be sub-
ject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of
insurance benefits.
GLS-APP-21s (3-18) Page 6 of 8
GLS-APP-21s (3-18) Page 7 of 8
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he 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 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 infor-
mation is guilty of a felony.
NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents
a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties un-
der state law.
FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide
false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
NEW YORK AUTOMOBILE FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for commercial insurance or a statement of claim for any commercial or per-
sonal insurance benefits containing any materially false information, or conceals for the purpose of misleading, infor-
mation concerning any fact material thereto, and any person who, in connection with such application or claim, knowingly
makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, dam-
age or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance
company, 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 value of the subject motor vehicle or stated claim for each violation.
NEW YORK OTHER THAN AUTOMOBILE FRAUD WARNING: 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.
GLS-APP-21s (3-18) Page 8 of 8
APPLICANT’S STATEMENT:
I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements
are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying. (Kan-
sas: This does not constitute a warranty.)
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an active owner, partner or executive officer)
PRODUCER’S SIGNATURE: DATE:
NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT:
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional
information as to the nature and scope of the report, if one is made, will be provided.
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ARTICLES APPLICATION CATERERS AND HALLS GENERAL LIABILITY AND (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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