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12/06/2016 16:36 5742333125 <br />UREATA <br />INSURANCE GROUP <br />Specially Human Services Division <br />XRC BILLING <br />CAMA7 AlluiRnICAN iNEUnANCC CnCUr <br />Specialty Human Services Division <br />SPECIAL EVENT QUESTIONNAIRE <br />PAGE 05/07 <br />Name of organization: 3t. t�lArv�care<� S r' O,Se- <br />FEIN: %. l ci i h, 5c $ Website address: www. S'4 rn r car shc� �8e . c7r <br />If you do not have a website, attach brochure and detailed description of daily activities of organization <br />1. Total number of events: 1 <br />2. Do you sponsor or co-sponsor any parades? If yesYES ❑ NOM <br />, <br />a. Numberof: floats horses participants <br />b. Do you require certlflcates of insurance, with $11,000,000 liability limits from all participants? YES ❑ NO'9 <br />3. Describe all mechanical or non -mechanical devices used at special events: <br />4• Are devices indicated provided and operated by a contractor? YES ❑ NO <br />If yes, do you obtain or require a certificate of insurance from the contractor YES ❑ NO <br />5. Complete chart below for each event. If additional space is required, provide Information on an attachment. <br />Event <br />Event <br />Event3 <br />Name of event: <br />W�n4t­cr t30J <br />Date, time and location of event: <br />s 'r ."_%t Fe6 <br />6101t7, <br />SoukhBenc�,ilt" <br />ou�C <br />Activities at event (use all applicable activity codes from <br />list below): <br />Total estimated attendshoe: <br />10� <br />Annual event? <br />YES NO <br />YES❑ NO❑ <br />YES NO <br />Has any claim or incident aver arisen cut of this event? <br />YE❑ NO <br />YES NO <br />YES❑ NO <br />Gross sales from admissions: <br />$ N 7 A, <br />$ <br />$S <br />Gross sales from food or non-alcoholic bevera a sales: <br />$ 0 <br />$ <br />Gross sales from alcohol sales: <br />$ N / A <br />$ <br />$ <br />Other rose sales: <br />$ iy / k <br />$ <br />$ <br />$ <br />Eme en medical personnel present? <br />YES NOQ <br />YES NO❑ <br />YES NO <br />Security ersonnei resent? <br />Golf carts or it at event? <br />YES NO <br />YES❑ NO❑ <br />YES NO <br />YES NO <br />YE:SfI NOfI <br />I Yesl-1 ntnfl <br />Activity Codes - for use above: <br />A. <br />Golf outing <br />B. <br />Wine tasting <br />C. <br />Dinner, gala or picnic <br />D. <br />Auction <br />E. <br />House tour <br />F. <br />Fashion or Art Show <br />G. <br />Bingo <br />H. Aircraft (motorized or not) <br />I. Animals <br />J. Athletic participation <br />K. Fireworks sates or show <br />L. Haunted house or trail <br />M. Mechanical rides <br />N. Non-mechanfcal entertainment <br />devices (e.g. bounce houses) <br />O. Parade (only entry of float into a parade) <br />P. Parade - participation in a parade (no -floats) <br />0. Parade -sponsorship of a parade <br />R. Use of any motorized vehicle(s) <br />Concert - describe type of music <br />T. Other - describe <br />S. If alcohol sales are indicated above, provide the following information; tKNA <br />a. Is any employee or volunteer of your organization responsible for serving alcohol? YES ❑ NO <br />b. What alcohol dispensing controls are In place; <br />c. Type of license for alcohol sales: Permit for event only ❑ Annual liquor license <br />Compfeted by: M cIli <br />4 <br />Date Completed: I Z. / 2- ( 1 to <br />F.36136f 1 N1 CamprchsM��a 4_e:-OB <br />