Event_Liquor Liability Event Questionnaire Form

Policy Number:*

Renewal Date:*

THE ATTACHED SCHEDULE OF EVENTS MUST BE COMPLETED IF MORE THAN ONE EVENT SCHEDULED FOR THE UPCOMING YEAR (RENEWAL TERM).

THE FOLLOWING QUESTIONS PERTAIN TO ALL EVENTS SCHEDULED. A SEPARATE APPLICATION IS REQUIRED FOR ANY EVENT NOT LISTED ON THE ATTACHED SCHEDULE.

1. What is the maximum number of patrons your special occasion permit allows for serving food and liquor?*

2. What are your hours of operation?*

3. Have you managed the event before (within the past 2 years)? Yes/No*

4. How many years of experience does the club have in managing this event?*

5. Are all liquor service staff 19 years of age or older? Yes/No*

6. Are all Rotarian/Rotaractors who serve liquor certified by one of the approved programs? Yes/No*

7. If you use an outside bartending service, who is certified? Yes/No

8. Do you check ID for all patrons who appear under the age of 25 years? Yes/No*

9. Is there a WRITTEN "Rules of Service" Policy? Yes/No And do you post it? Yes/No*

10. Does the WRITTEN "Rules of Service" Policy: (Yes or No for each)*

11. Are all volunteers/staff aware of their Legal Obligations to: (Yes or No for each)*

12. Are server staff required to file written Incident Reports? Yes/No*

13 a. Has your club ever been refused a liquor licence? Yes/No*

13 b. If Yes, give details*

I may have provided personal information in this document and by other means and I may in the future provide further personal information. Some of this personal information may include, but is not limited to, my credit information and claims history. I authorize my broker or insurance company to collect, use and disclose any of this personal information, subject to the law and to my broker’s or insurance company’s policy regarding personal information, for the purposes of communicating with me, assessing my application for insurance and underwriting my policies, renewals, changes of coverage, evaluating claims, detecting and preventing fraud, and analyzing business results. I confirm that all individuals whose personal information is contained in this document have authorized that I agree to the above on their behalf.

I declare that to the best of my knowledge, all the information on this questionnaire is true and that these statements are the declarations upon which insurance coverage is provided. Signing this form does not bind the applicant or the Insurer to complete the Insurance.

Date*

Date

Signature*

ROTARY CLUB SCHEDULE OF EVENTS, LOCATIONS AND DATES

THIS FORMS PART OF THE LIQUOR LIABILITY QUESTIONNAIRE AND MUST BE COMPLETED IN ORDER TO PROVIDE COVERAGE (if more than one event during upcoming year):

Event Description	Location	Allowable # People/Permit	Date