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Scottsdale Insurance Company Home Office: One Nationwide Plaza (Risk Placement Services, Inc.)

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GLS-APP-85g (5-13) Page 1 of 5
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
Liquor Liability—Special Event Application
Complete a separate application for each event.
Applicant’s Name:
Mailing Address:
Event Location:
Website 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 REQUESTED
Each Common Cause Aggregate
$ $
1. Description of event (attach any flyers, brochures, etc.):
a. Maximum daily attendance: Total attendance:
b. Length of event:
Less than o
ne day (number of hours) or More than one day (number of days)
c. Does event advertising include responsible drinking public service messages? ................................. Yes No
d. Is the applicant in the business of manufacturing, distributing, selling, serving or furnishing alco-
holic beverages? ...................................................................................................................................
Yes No
e. Will applicant’s employees pour or serve alcoholic beverages? ...........................................................
Yes No
f. Will event volunteers be allowed to pour or serve alcoholic beverages? ............................................
Yes No
g. Are attendees allowed to bring their own alcoholic beverages?
................................................................. Yes No
GLS-APP-85g (5-13) Page 2 of 5
h. Will attendees to the event be allowed to self-serve themselves alcoholic beverages? ...................... Yes No
i. Is liquor poured or served by others hired by the applicant or vendors at the event? ..........................
Yes No
If yes, do they have Liquor Liability coverage? .....................................................................................
Yes No
Does applicant obtain Certificate of Insurance as evidence of their Liquor Liability coverage? ...........
Yes No
2. Is this the first time applicant has held this event? ...............................................................................
Yes No
If no, number of times previously held:
3. Has applicant ever been assessed a fine for violation of a law concerning the sale of alcohol, or
had their liquor license suspended/revoked? ........................................................................................
Yes No
If yes, when and why?
4. Name on liquor license:
Type of liquor license:
5. Estimated liquor receipts: $ Other receipts: $
6. Average price for: beer $ wine $ liquor $
7. What is the liquor budget (cost) if liquor is being provided at no charge at the event? ................ $
8. Number of servers:
9. Have all servers been through alcohol awareness server training (i.e., TIPS, TOPS)? ..................... Yes No
Type of course:
10. How often does the applicant review liquor liability laws with employees (including penalties for serving intoxi-
cated customers)?
11. Are procedures in place regulating the sale of alcohol to minors and those under the influence? Yes No
If yes, describe:
How is age of customer verified?
Once age is verified, are wristbands or hand-stamps used to identify eligible attendees? ......................... Yes No
Are non-drinking designated drivers identified and issued separate wristbands or hand-stamps? ............
Yes No
12. Percent of attendees: 25 & under
% 26-30 % Over 30 %
13. Is there a designated area for serving and drinking alcohol? (i.e., beer garden, bar area, etc.) ...... Yes No
If yes, is there an entrance fee or cover charge? ........................................................................................
Yes No
If yes, what is the amount? ....................................................................................................................... $
14. Is there a limited number of alcoholic drinks “per purchase?” ........................................................... Yes No
If yes, maximum number allowed:
15. Are there on-site facilities for use to allow attendees to sober up prior to leaving the event? ........ Yes No
16. Are alcohol sales ended a minimum of one hour before the end of the event? .................................
Yes No
17. Security Activities:
Security provided (check all applicable):
Bouncers Doormen Off Duty Police Contracted Security Guards
Armed Unarmed
Other—Describe:
Are sobriety checks used to identify possible intoxicated attendees as they leave the event? .................. Yes No
18. Any firearms allowed on event premises? .............................................................................................
Yes No
GLS-APP-85g (5-13) Page 3 of 5
19. Are there procedures for handling violent or disruptive patrons? ...................................................... Yes No
If yes, describe:
20. Additional Insured Information:
Name Address Interest
21. During the past three years, has any company ever canceled, declined or refused similar insur-
ance to the applicant? (Not applicable in Missouri) ..................................................................................
Yes No
If yes, explain:
22. Prior Carrier Information:
Year: Year: Year:
Carrier
Policy No.
23. Loss History:
Indicate all Liquor Liability claims or losses (regardless of fault and whether or not insured) or occurrences
that may give rise to claims for the prior three years.
Check if no losses in the last three 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.
I understand that Liquor Liability is a separate coverage part and the limits requested in this application apply solely to
liquor liability coverage and may differ from the General Liability limits afforded in my commercial package policy.
I further understand that the Company is relying upon statements I have made in this application as an inducement to
provide insurance for Liquor Liability coverage.
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 to Oregon).
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.
GLS-APP-85g (5-13) Page 4 of 5
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 of the third degree.
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 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
under 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.
GLS-APP-85g (5-13) Page 5 of 5
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 civil penalty not to exceed five thousand dollars
and the stated value of the claim for each such violation.
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 state-
ments are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying.
(Kansas: This does not constitute a warranty.)
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: _______________________________________________________ DATE:
(Must be signed by active owner, partner or executive officer)
PRODUCER’S SIGNATURE: ______________________________________________________ DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IOWA LICENSED AGENT:
(Applicable in Iowa Only)
IMPORTANT NOTICE
As part of the underwriting procedure, a routine inquiry may be made which will provide 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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Completed 7 February 2021

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