Fillable Caterers and Halls General Liability and Miscellaneous Articles (RT Specialty)

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Caterers and Halls General Liability and Miscellaneous Articles (RT Specialty)

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  • 25 check-boxes
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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
1-800-423-7675 • Fax (480) 483-6752
www.scottsdaleins.com
Caterers and Halls General Liability and Miscellaneous Articles Application
Applicant’s Name:
Mailing Address:
Location Address:
Web site Address:
Agency Name:
Agent:
Address:
E-Mail:
Phone:
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”
Applicant is: Individual Corporation Partnership Joint Venture
Limited Liability Company Other (Specify):
Limits Of Liability and Deductible Requested:
General Aggregate (other than Products/Completed Operations) $
Products & Completed Operations Aggregate $
Personal & 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 $
Miscellaneous Articles:
Miscellaneous Articles Coverage and Deductible
$ 2,500 (included)/$250 deductible
$ 5,000/$250 deductible
$ 7,500/$250 deductible
$10,000/$250 deductible
GLS-APP-21s (7-12) Page 1 of 5
Submit Application
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 square footage?
8. Does applicant have a parking area? ...................................................................................................... Yes No
If yes, is parking area well lit? ...................................................................................................................... Yes No
9. Does applicant provide valet parking service? ...................................................................................... Yes No
If yes, is parking done by insured’s employees? ......................................................................................... Yes No
If yes, where is Garage Liability Coverage insured?
If no, advise by whom:
10. Does applicant operate a limousine service for guests? ...................................................................... Yes No
If yes, where is Automobile Liability Coverage insured?
11. Number of sandwich/catering or ice cream trucks:
Advise Automobile Liability carrier: Limits:
12. 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
13. Does applicant have Workers’ Compensation coverage in force? ...................................................... Yes No
14. Where is food prepared? Commercial kitchen Other If other, please provide complete details:
15. Does applicant package and sell food under their own label? ............................................................. Yes No
16. Are health department regulations followed? ........................................................................................ Yes No
17. How are dishes and linens cleaned and sanitized?
18. Describe food storage procedures:
GLS-APP-21s (7-12) Page 2 of 5
19. Are records kept on food suppliers? ....................................................................................................... Yes No
20. Equipment:
Are any of the following used?
Amusement devices (describe: )
Barricades Portable restrooms
Dance floors Space heaters
Folding chairs/tables Tents
Grills (electric, gas, LPG) (describe: ) Tiki torches/live flames
21. Does applicant separately rent equipment to others? .......................................................................... Yes No
If yes, what are receipts?
22. Does applicant subcontract any operations? ........................................................................................ Yes No
If yes:
a. Description of operations subcontracted?
b. Annual cost of subcontracted work:
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:
23. Additional Insured Information:
Name Address Interest
24. Schedule Of Hazards:
Loc.
No.
Classification Description
Class.
Code
Exposure
Premium Basis
(s) Gross Sales
(p) Payroll
(a) Area
(c) Total Cost
(t) Other
25. 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:
GLS-APP-21s (7-12) Page 3 of 5
26. 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:
27. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
28. Prior Carrier Information:
Year:
Year:
Year:
Year:
Year:
Carrier
Policy No.
Coverage
Occurrence or
Claims Made
Total Premium
29. Loss History:
Ind
icate 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)
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.
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 Nebraska, Oregon and Vermont.
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
addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any in-
surer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a
felony in the third degree.
GLS-APP-21s (7-12) Page 4 of 5
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.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly and 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 knowingly and with intent to defraud any insurance company 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.
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 Tennessee, Virginia and Washington): It is a crime to knowingly provide false, in-
complete or misleading information to an insurance company for the purpose of defrauding the company. Penalties in-
clude imprisonment, fines and denial of insurance benefits.
NOTICE TO NEW YORK APPLICANTS (Other than automobile): 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.
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.
GLS-APP-21s (7-12) Page 5 of 5
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Caterers and Halls General Liability and Miscellaneous Articles (RT Specialty)

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Completed 13 December 2020

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