Fillable Special Events & Bingo SUPPLEMENTAL APPLICATION Please complete (Risk Placement Services, Inc.)

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Special Events & Bingo SUPPLEMENTAL APPLICATION Please complete (Risk Placement Services, Inc.)

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MRA PNP Special Event/Bingo Supp (1/07) Page 1 of 2
Special Events & Bingo
SUPPLEMENTAL APPLICATION
Please complete a separate supplemental application for each event and/or location.
Named Insured
For each special event or fundraising activity you sponsor or participate in, please attach the following:
- Schedule of Events
- Copies of Cont
racts, Lease agreements and Hold Harmless Agreements between event management and any other party where the
insured assumes the other’s liability.
A. Special Events
1. Location:____________________________________________________Event Date(s):____________________________
Number of participants:_________________________ Spectators: _______________________________
Ages of participants:___________________________ Ages of spectators:__________________________
2. Describe the nature of the event:________________________________________________________________________
3. How many events do you sponsor annually?__________________________
4. Number of your staff present at the event?____________________ Number of Volunteers:_________________________
5. What is your experience with this type of event?___________________________________________________________
If none, have you hired an event manager who has experience?
Yes No
6. Who supervises youth at the event?_____________________________________________________________________
7. Who provides security?_________________________________ What type of security?___________________________
Are security personnel armed?
Yes No
If an outside entity provides security, do you obtain a certificate of insurance from them
and are you named as an additional insured on their insurance? Yes No
8. Is liquor being served? Yes No
If yes is a charge being made?
Yes No
Are you furnishing the liquor?
Yes No
What percentage of revenues are from liquor sales?_______________%
Is a drink maximum imposed on attendees?
Yes No
Is there a formal control in place to avoid serving alcohol to minors?
Yes No
If yes, please explain:________________________________________________________________________________
_________________________________________________________________________________________________
9. Are certificates of insurance obtained from all vendors and do they name you as additional insured?
Yes No
10. If this is an athletic event, please list the numbers & types of medically trained personnel present during the event::
RN:____ LPN:____ EMT:____ MD:____ PA:____ Other(describe):__________________________________________
11. List any additional insureds needed for this event (attach another sheet if more space needed):
Name:________________________________________ Name:_____________________________________________
Address:______________________________________ Address:___________________________________________
City,State,Zip:__________________________________ City,State,Zip:_______________________________________
Relationship to event:____________________________ Relationship to event:_________________________________
12. Will you be using bleachers?
Yes No
If yes, are they portable?
Yes No
13. Will you have any mechanical rides, non-mechanical rides or entertainment devices? Yes No
If yes, describe all rides and devices:___________________________________________________________________
________________________________________________________________________________________________
MRA PNP Special Event/Bingo Supp (1/07) Page 2 of 2
B. BINGO
(
Complete only if you sponsor bingo games or games are held on your premises)
:
14. How many games are held weekly _________________
15. Do you hold regular activities simultaneously with Bingo games? Yes No
16. Are you responsible for setting up the tables and chairs, lay-out, clean up, and all premises maintenance,
including snow removal, mopping wet floors, bathrooms, etc.?
Yes No
If no, who is?_____________________________________________________________________
Do you obtain a certificate of insurance from them and are you named as an additional insured on their
insurance policy?
Yes No
17. Do you check all chairs to make sure they are in good repair and good working order? Yes No
18. Are you responsible for snacks or concessions? Yes No
If no, who is?_____________________________________________________________________
Do you obtain a certificate of insurance from them and are you named as an additional insured on their
insurance policy?
Yes No
19. Do you provide a staff member to supervise every time your facility is rented out?
Yes No
20. Who monitors the capacity requirements of the facility?____________________________________
21. What are the number of bingo admissions annually?______________________________________
22. Who provides security?_________________________________ What type of security?_______________________
Are security personnel armed?
Yes No
If an outside entity provides security, do you obtain a certificate of insurance from them
and are you named as an additional insured on their insurance? Yes No
The undersigned represents that all statements and answers to questions are true, complete and accurate and that there has
been no suppression or misstatement of fact.
THE APPLICANT ACCEPTS NOTICE THAT HE/SHE IS REQUIRED TO PROVIDE WRITTEN NOTIFICATIONS TO THE
COMPANY OF ANY CHANGES IN THE RESPONSES GIVEN TO THIS APPLICATION THAT MAY HAPPEN BETWEEN
THE SIGNATURE DATE BELOW AND ANY PROPOSED EFFECTIVE DATE.
The undersigned is an authorized representative of the applicant and certifies that reasonable enquiry has been made to
obtain the answers to questions on this application. He/She certifies that the answers are true, correct and complete to the
best of his/her knowledge.
Date Signed Signature of Applicant
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Special Events & Bingo SUPPLEMENTAL APPLICATION Please complete (Risk Placement Services, Inc.)

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Completed 23 November 2020

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