AMERICAN SPECIALTY
x FAPRESS
SPECIAL EVENTS PROGRAM QUESTIONNAIRE
POLICYHOLDER INFORMATION
Named Insured (as will appear on policy): Virginians for Alternatives to the Death Penalty
Address: P.O. Box 12222
Richmond VA 23241
City State Zip
Contact Name: Michael Stone
Phone: 434-960-7779
E-mail Address: office@vadp.org
GENERAL INFORMATION
1. Event Start Date: 10/20/2018 Event End Date: 10/20/2018
2s Event Name: VADP Awards Luncheon
3. Event Venue: Vienna Moose Lodge
4. Event Address: 9616 Courthou:
City: Vienna
5. What general type of event are you 1 having? Luncheon - Fund Raising
6. Estimated Event attendance (All days combined): 250
Te Number of years this event has taken place: 3-5
8. Website (if applicable): https://www.vadp.org/vadp-2018-awards-luncheon/
9. Description of event and any ancillary activities: This will be our fourth awards luncheon. Tickets include a lunch
and non-alcoholic beverages. We will have a keynote speaker and an awards presentation.
The event will take place on Saturday. October 20. 2018 from noon to 2:00pm.
10. Have you had more than $5,000 of total claims in the last three years? ClYes KI No
11. Do you have any of the below activities? OlYes KINo
+ After-Hours Parties (e.g. After Prom, Graduation Night, Retirement)
+ Amusement Rides, Mechanical Devices, Rock Climbing Walls, or Inflatables
+ Animal Rides
+ Animal Shows (e.g. Cat, Dog, Horse, Livestock Judging)
+ Cave Explorations
+ Fairs
+ Fireworks or Pyrotechnics
+ Fishing Derbies
+ Fraternity or Sorority Parties
+ Gun Shows/Knife Shows/Shooting Events
+ Haunted Houses
+ Motorsports Events (including Demolition Derbies, Mud Bogs, Tractor Pulls, Races, and Stunt Shows)
+ Overnight Accommodations or Camping Facilities
+ Overnight Lock-ins
+ Parades
+ Political Rallies
+ Rodeos
+ Sporting Events
+ Water Activities
+ Wine Tastings
Express SPECIAL EVENTS (11/17) Page 1 of 4 SP # 7665673
American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and A
S Insurance & Risk Services Agency. Alll rights reserved.
SHORT TERM SPECIAL EVENTS - ALCOHOL
If this event includes alcohol, please complete the Host Liquor or Retail Liquor section below.
HOST LIQUOR (Not available in AL, IN, NH, NM, ND, VT)
Alcohol is provided to guests for no charge, bring your own beverage, or alcohol can be purchased from a third party
(restaurant, caterer, vendor, etc.) as long as the event host does not receive a portion of the receipts.
Please select how Alcoholic beverages are provided (select one of the following):
C1 Distributed free of charge
+ Are individuals charged to attend the event? 1 Yes [INO (yes, please complete the Retail Liquor section below)
o Alcohol is served by (select one):
L) Event Host, Employees, or Volunteers
= Are there designated servers for the alcoholic beverages who have been instructed to not
serve liquor to minors or intoxicated guests DYes [INo
(If answered “NO”, this event is ineligible for coverage)
C1 Licensed Caterer or the Venue
1 Sold by a third party
+ Are any proceeds from the sale of alcohol shared with the event? OlYes LINO
(/f yes, please complete the Retail Liquor section below)
1 Bring Your Own Beverage
RETAIL LIQUOR (Not Available in AL, IA, MI, VT)
Alcohol is sold, event tickets/dinner/admission include alcohol, insured holds a liquor license or permit, or any revenue is
received (shared) from a third party selling alcohol.
1. Estimated revenue the event will receive from the sale of alcohol?
2s Please select how alcoholic beverages are priced:
CJ Included with the cost of the ticket/dinner/admission
CJ Sold at the event
3. Who holds the liquor license?
C1 Insured
(please complete Supplement questions below)
1 Caterer/Vendor
Is the caterer/vendor serving the alcohol? OYes (1 No
(If NO, complete Supplement questions 3-10 below)
OI Facility
Is the facility serving the alcohol? (Yes [] No
(If NO, complete Supplement questions 3-10 below)
SUPPLEMENT
1. Name of the liquor license/permit holder:
2. Liquor license/permit number:
3 Are ID's checked at the event? Yes [J No
(If no, this event is ineligible.)
4, Has a fine ever been received or liquor license revoked or suspended? (1 Yes [J No
(If yes, this event is ineligible.)
5; Are alcohol sales and consumption contained within a fixed/secured area? 1 Yes [J No
(If no, this event is ineligible.)
6. Have servers had formalized alcohol awareness training? 1 Yes [] No
(/f no, this event is ineligible.)
Express SPECIAL EVENTS (11/17) Page 2 of 4 SP # 7665673
American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and A
S Insurance & Risk Services Agency. Alll rights reserved.
7, Choose the type of formalized alcohol awareness training:
(1 TIPS (Training for Intervention Procedures)
(1 TAMs (Techniques of Alcohol Management)
CJ State Designated Program:
(1 Other:
8. Are alcohol sales stopped at least one hour prior to the end of the event? C1 Yes [] No
(/f no, this event is ineligible.)
9. ls a purchase of two beverages or less at a time enforced? Yes [1 No
(If no, this event is ineligible.)
10. Is a designated driver program in place (call a cab, etc.)? (Yes [] No
(If no, this event is ineligible.)
AMERICAN SPECIALTY INSURANCE & RISK SERVICES, INC. for the insuring Company shall be permitted but not
obligated to inspect the INSURED'S property and operations for UNDERWRITING AND/OR LOSS CONTROL
PURPOSES at any time. Neither the right to make an UNDERWRITING AND/OR LOSS CONTROL EVALUATION nor
the making thereof nor any report thereof shall constitute an undertaking, on behalf of or for the benefit of any insured, or
others, to forecast any accident or its severity or determine or warrant that such property or operations are safe or
healthful, or are in compliance with any engineering standards, rules, or regulations. The establishment of underwriting
criteria and UNDERWRITING AND/OR LOSS CONTROL EVALUATIONS ARE FOR THE SOLE PURPOSE OF
DETERMINING THE INSURABILITY OF CERTAIN PROPERTY AND OPERATIONS, underwriting, and seeking to
reduce claims against insurance and are not for the benefit of any insured or third party. The Insured is solely responsible
for the safety of its property and operations and shall not rely upon any UNDERWRITING AND/OR LOSS CONTROL
evaluations or activities to determine the safety of its property or operations and shall not diminish or forego its own safety
practices and procedures.
| UNDERSTAND THAT ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION MAY BE SUBJECT TO
CRIMINAL AND CIVIL PENALTIES.
| hereby represent and confirm that the above information, to the best of my knowledge, is true and correct and further
certify that | have read all of the questions and answers of these applications.
| confirm that | have read and understand the individual state fraud notices which are a part of this American Specialty
application for coverage. | acknowledge and understand that any person or persons who knowingly and with intent to
defraud any insurance company commits a fraudulent insurance act, which is a crime, is subject to criminal and civil
penalties.
IT IS UNDERSTOOD AND AGREED THAT THE COMPLETION OF THIS APPLICATION SHALL NOT BE BINDING
EITHER TO THE PROPOSED INSURED OR TO THE COMPANY UNTIL ACCEPTED BY THE COMPANY OR
COMPANIES IN WRITING.
Date Signature of Insured or Authorized Representative Title
Send completed form to: American Specialty Insurance & Risk Services, Inc.
7609 W. Jefferson Boulevard
Suite 100
Fort Wayne, IN 46804
Phone: (800) 245-2744
E-mail: apply@americanspecialty.com
Express SPECIAL EVENTS (11/17) Page 3 of 4 SP # 7665673
American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and A
S Insurance & Risk Services Agency. Alll rights reserved.
Generic Fraud Warning Language:
Any person, who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
NOTICE TO RESIDENTS OF:
Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or
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. *Applies in MD Only.
licable in
It is unlawful to knowingly provide false, incomplete, or misleading facts or information 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 policyholder or claimant for the purpose of defrauding or
attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Applicable in FL and OK
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an
application containing any false, incomplete, or misleading information is guilty of a felony (of the third degree)*. “Applies
in FL Only.
Applicable in KS
Any person who, knowingly and with intent to defraud, presents, causes to be presented 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 statement 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 conceals, for the
purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.
Applicable in KY, NY, OH and PA
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 to exceed five thousand dollars and the stated value of
the claim for each such violation)*.
*Applies in NY Only.
Applicable in ME, TN, VA and WA
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 and denial of insurance benefits.
*Applies in ME Only.
Applicable in NJ
Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
Applicable in OR
Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an
application containing a false statement as to any material fact may be violating state law.
Applicable in UT
Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or
fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health
care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison.
EDITION 11/17
Express SPECIAL EVENTS (11/17) Page 4 of 4 SP # 7665673
American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency, American Specialty Insurance & Risk Services Agency, and A
S Insurance & Risk Services Agency. Alll rights reserved.
CC BY-NC-SA 4.0