USER LIABILITY PACKET 2016
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1 USER LIABILITY PACKET 2016
2 Table of Contents Section Page(s) User Application (Endorsement Request Form) 3 Vendor/Concessionaire Log 4 Parade Participant Log 5 Liquor Liability Supplement 6-7 Payment Instructions 8
3 Haas & Wilkerson Insurance will provide General Liability coverage for licensees in the mentioned event under a master insurance policy. Coverage for concessionaires and exhibitors includes public liability and property damage liability with a $1,000,000 each occurrence limit and $3,000,000 aggregate & products liability limit. LIQUOR LIABILITY IS SPECIFICALLY EXCLUDED. PLEASE CALL OUR OFFICES IF YOU NEED LIQUOR LIABILITY. General Liability coverage provided conforms with the requirements of the contractual agreement with your venue. This insurance is excess over any other valid and collectible insurance. LICENSEES INSURANCE PROGRAM: General Liability coverage will be provided for the period of the Fair or Scheduled Event only, to include set-up and tear-down.! Amusement Rides/Devices (Includes: Gyroscopes & Spaceballs)! Body Piercing & Massages & Wraps! Bungee Attractions! Child Care! Climbing Walls! Concert Promoters/Performers! Dart Games! Dunking Booths! Fireworks Operator ITEMS LISTED BELOW ARE NOT ACCEPTABLE FOR ENDORSEMENT! Gun Shows! Haunted Houses! Henna Tattoos! Inflatable Amusements (Includes: Moonwalks, Bounces, & Pillows)! Mazes! Medical/Dental Testing & Screenings! Motorsports Events! Permanent Tattoos! Playground Equipment! Pseduo-Fighting/Wrestling Activities! Rodeo Events! Roller/Ice Skating! Sales of Autos or Auto Parts! Sales of Herbal Supplements! Sales of Tobacco! Sales of Weight Loss/Stop Smoking Aids, Pills, Patches! Simulators! Wheelchair/Stroller Rentals ITEMS LISTED BELOW REQUIRE ADDITIONAL PREMIUM & MUST BE APPROVED BEFORE ENDORSEMENT " Concerts-Local & Regional talent only " Exotic Animals " Golf Carts/Scooters " Liquor Liability " Pony Rides " Sales of Pets/Rodents Entertainers (Includes: mimes, clowns, balloon artists, magicians, walking characters, face painters, sketch artists, choirs, etc.) ENDORSEMENT REQUEST FORM TODAY S DATE: APPLICANT NAME: INSURED NAME (Fair/Fest): NAME OF EXHIBIT/CONCESSION/VENDOR: APPLICANT FULL ADDRESS: TYPE OF EVENT/PRODUCT(S) PROVIDED: WILL THERE BE ANY ATHLETIC ACTIVITIES, EVENTS, OR COMPETITIONS, OR ANY RECREATIONAL PHYSICAL ACTIVITIES OR CONTESTS BETWEEN INDIVIDUALS OR AS A GROUP? Yes IF YES, PLEASE EXPLAIN: APPLICANT PHONE: EVENT DATE(S): LIQUOR LIABILITY REQUIRED? *Must call for acceptability and/or premium PREMIUM: $ EST. ATTENDANCE: PERSONAL CHECKS FROM EVENT SPONSOR WILL NOT BE ACCEPTED ACE SPECIAL EVENT PRICING Attendance Based Events Meeting, Weddings, Picnics, Socials, Dinners, Trade Shows, Small Animal Shows Per Day Based Events TOTAL ATTENDANCE PREMIUM EVENTS PER DAY PREMIUM Under 200 $65 Flea Markets $105/day $90 Livestock includes-cattle, goat, horse, mule, pig, sheep 501 1,500 $115 Livestock Sales $105/day 1,501 3,000 $165 Livestock Show $80/day 3,001 5,000 $215 Christmas Tree Lot $25/day 5,001 7,500 $265 Pumpkin Patches $25/day 7,501 10,000 $315 Over 10,000 Please Call VENDOR/CONCESSIONAIRE/EXHIBITOR PREMIUM PARADE PARTICIPANTS PREMIUM First Booth (each exhibitor) $70 Walking Units $25/unit Each Additional Booth (same exhibitor) $50 Mobile Units $55/unit Each Game Booth $85 Equestrian Units $80/unit Please contact: Adam Keener Phone: Fax: userliab@hwins.com
4 INSURED: EVENT DATE: EVENT NAME! Amusement Rides/Devices (Includes: Gyroscopes & Spaceballs)! Body Piercing & Massages & Wraps! Bungee Attractions! Child Care! Climbing Walls! Concert Promoters/Performers! Dart Games! Dunking Booths! Fireworks Operator ITEMS LISTED BELOW ARE NOT ACCEPTABLE FOR ENDORSEMENT! Gun Shows! Haunted Houses! Henna Tattoos! Inflatable Amusements (Includes: Moonwalks, Bounces, & Pillows)! Mazes! Medical/Dental Testing & Screenings! Motorsports Events! Permanent Tattoos! Playground Equipment! Pseduo-Fighting/Wrestling Activities! Rodeo Events! Roller/Ice Skating! Sales of Autos or Auto Parts! Sales of Herbal Supplements! Sales of Tobacco! Sales of Weight Loss/Stop Smoking Aids, Pills, Patches! Simulators! Wheelchair/Stroller Rentals ITEMS LISTED BELOW REQUIRE ADDITIONAL PREMIUM & MUST BE APPROVED BEFORE ENDORSEMENT " Concerts-Local & Regional talent only " Exotic Animals " Golf Carts/Scooters " Liquor Liability " Pony Rides " Sales of Pets/Rodents Entertainers (Includes: mimes, clowns, balloon artists, magicians, walking characters, face painters, sketch artists, choirs, etc.) VENDOR/CONCESSIONAIRE PRODUCT/SERVICE PROVIDED # BOOTHS PREMIUM
5 ATTACHMENT TO USERS LIABILITY POLICY FOR PARADE PARTICIPANTS INSURED: PARADE DATE: PARADE NAME PARADE PARTICIPANT PRICING Walking Unit *Mobile Unit Equestrian Unit $25/unit $55/unit $80/unit *If the unit is licensed for on road use and subject to compulsory or financial responsibility law or other motor vehicle insurance law, it CANNOT be added to this policy. PARADE UNIT TYPE OF UNIT # UNITS PREMIUM
6 THIS IS NOT A BINDER. INCOMPLETE APPLICATIONS WILL BE RETURNED FOR COMPLETION. Liquor Liability Supplement to Users Liability Policy: (Liquor Liability not available in the following states: AL, DC, VT) Named Insured: Legal Name of Applicant: dba (if applicable): 1. Name Liquor License is in: 2. Type of Liquor License: 3. Type(s) of alcoholic beverage sold: Event Date: State Event is held: Type of Event if not Booth during event: 4. Do you sell Liquor at any other location other than this fair? Prior Experience 5. Has your liquor license ever been revoked or suspended? 6. Have you ever been fined by any alcohol regulatory agency? 7. Have you ever incurred a liquor liability claim? 8. Has your liquor liability insurance ever been cancelled or non-renewed? **If yes to 4, 5, 6, 7 or 8 above, please explain:
7 Liquor Operations 9. Anticipated gross liquor sales: $ Last year s gross liquor sales: $ 10. Who serves alcohol? Employees/Volunteers Charitable organizations Other If other, please explain: 11. Are servers trained in alcohol awareness? Yes If no, please explain: 12. Are procedures and chain of authority established for refusing to serve? Yes If no, please explain: 13. Opening and closing hours of alcohol sales: Open: AM PM Close: AM PM A. If alcohol sales are not shut down at least 30 minutes prior to the premises closing, please explain: 14. Please explain procedures for checking ID: 15. Describe limits on the number of beverages purchased at one time: 16. Are patrons allowed to carry alcoholic beverages onto premises? Yes If yes, please explain:
8 PAYMENT INSTRUCTIONS Acceptable forms of payment: Cashier s Check Money Order The above payments can be mailed to 4300 Shawnee Mission Parkway, Fairway KS *Personal/Business Checks and Credit Cards will not be accepted. or Haas & Wilkerson Insurance has partnered with Western Union Quick Collect to offer our customers an alternative way to quickly pay the premium for insurance. Please note, there will be a transaction fee added to the premium payment. To use Quick Collect: 1. Call Western Union at to find a location near you or log on to for online payment instructions. 2. Payments transmitted over the internet will be billed to your credit card. 3. Whether payment is in person or over the internet, fill out the Quick Collect Payment form completely, including the following information: Pay to: Code city: State: Account #: HAAS & WILKERSON INSURANCE HAAS KS RRM-KS (For online payments, use Account # RRM) If this option is selected, please fax the Insurance Request Form and the Western Union Quick Collect confirmation to Contact: Adam
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