Fillable SPECIAL EVENTS APPLICATION FORM ELIGIBILITY QUESTIONS 3. Is (RT Specialty)

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SPECIAL EVENTS APPLICATION FORM ELIGIBILITY QUESTIONS 3. Is (RT Specialty)

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ATR-142 Special Events Application Page 1 of 2
SPECIAL EVENTS
APPLICATION
FORM
THE ANSWERS TO THESE QUESTIONS FORM PART OF AN APPLICATION FOR INSURANCE ONLY. NOTHING IN THIS APPLICATION
SHALL BE DEEMED AN AGREEMENT TO PROVIDE INSURANCE AND UNDERWRITERS MAY DECLINE TO OFFER
COVERAGE OR
OFFER COVE
RAGE ON TERMS THAT DIFFER FROM THE COVERAGE SOUGHT B
Y THE APPLICANT.
ELIGIBILITY QUESTIONS
1. In which state is the Special Event to be held:
2. W hat type of Special Event is to be held:
3. Is the event: Private Special Event Business or Organisational Special Event Special Event Open to General Public
4. W ill alcohol be consumed during this event?
Yes No
5. W ill the alcohol be dispensed by a third party professional bar tenders or by trained servers
who have completed a formal alcohol training course such as TIPS and do they have a liquor
liability policy with limits equal to or exceeding the CGL requested?
Yes No
6. Does the daily number of attendees exceed 3000 or overall event attendance exceed 15000?
Yes No
7. Does the Special Event finish after 2 a.m.?
8. Has the applicant had any policy of insurance cancelled or non-renewed in the last 3 years?
9. Has the applicant ever been convicted of the crimes of arson or insurance fraud?
10. Does the Special Event include any of the following – Yes No
Activites:
Animal Rides or Petting; Bouncy Castles, Moon Bouncers or other Inflatable Devices; Dunking Tanks; Hay
Rides; Haunted Houses; Hot Air Ballooning; Mechanical Amusement Rides; Motorised Sports; Paintball;
Powered or Motorised Model Aircrafts; Airplanes, Helicopters or Vehicles; Rock Climbing; Rodeo; Roller or
Ice Skating; Skateboarding; Skiing; Snowboarding; Soap Box Derbies or Trampolining?
Exposures:
Animals; Temporary Event Bleachers; Camping or Overnight Exposure; Child Care; Firearms;
Fireworks/Pyrotechnics; Fraternity or Sorority Exposure; Heavy Rock, Hip Hop or Rap Music; Armed
Security or Security with Dogs or Water Hazards?
11. If you are the special event organiser do all exhibitors, vendors, contractors and sub-contractors carry CGL liability limits
equal or in excess of CGL limit requested? Yes No Not Applicable
12. Is this a repeat or annual event? Yes No
13. Has the previous Special Events had or has pending any losses, claims, or lawsuits? Yes No
Yes
No
Yes
No
Yes
No
Submit Application
ATR-142 Special Events Application Page 2 of 2
APPLICANT DETAILS
Name and Mailing Address of Applicant:
State
Zip code
Telephone
Email
Address of Property to be Insured:
State
Zip code
Name and Address of Retail Broker:
State
Zip code
CONTACT DETAILS
Contact Name
Telephone
Email
COVERAGE AND PROPERTY DETAILS
14. Special Event Name:
15. Special Event Start Date:
16. Special Event Number of Days:
17. Maximum Special Event attendees per day: 0-50 51-250 251-1000 1001-2000 2001-3000
18. Maximum Special Event attendees overall:
19. What time is the Event expected to end: Before Midnight Before 1 a.m. Before 2 a.m.
20. Please enter the CGL limit required for the Special Event: $100,000/$100,000 $300,000/$300,000 $500,000/$500,000
$1,000,000/$1,000,000 $1,000,000/$2,000,000
21. Is TRIPRA coverage required: Yes No
22. Do you require Medical Pay Cover: Not Required $1,000 $2,000 $3,000 $4,000 $5,000
23. If required, please enter details of Additional Insured:
DECLARATION
THE ANSWERS GIVEN IN THIS APPLICATION ARE CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT THESE ANSWERS
W ILL FORM PART OF A POLICY THAT IS SUBSEQUENTLY OFFERED. I ALSO UNDERSTAND THAT ANY FALSE STATEMENT MAY
VOID THE INSURANCE IN ITS ENTIRETY OR RESULT IN A CLAIM BEING DENIED.
ANY PERSON W HO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN
APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF
MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, W HICH IS A
CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND (NY: SUBSTANTIAL) CIVIL PENALTIES. (NOT APPLICABLE IN CO, HI, NE, OH,
OK, OR, VT FOR W HICH SEE A
TTACHED). IN DC, LA, ME, TN AND VA
, INSURANCE BENEFITS MAY ALSO BE DENIED.
Applicant’s Signature
Retail Broker’s Signature
Date
Date
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SPECIAL EVENTS APPLICATION FORM ELIGIBILITY QUESTIONS 3. Is (RT Specialty)

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Completed 31 July 2020

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