ALPHA PHI ALPHA FRATERNITY, INC. ®
2313 SAINT PAUL ST., BALTIMORE, MD 21218-5211 SPECIAL EVENT CHECKLIST
Special Events sponsored by Chapters, Districts and Regions are covered under the general liability policy. If any event other than a regular business meeting is held, the Special Events Checklist Application, must be completed and submitted to the Corporate Headquarters for approval at least (21) twenty-one days prior to the event date. These events require the written approval of the Corporate Headquarters before they are held by the chapter. The Corporate Headquarters will determine if the event poses too great of a risk to the Fraternity to be covered under the current policy. If the potential liability exposure of the event is deemed to be extreme, the chapter will be asked to purchase a separate liability policy for the event or pay a surcharge for the coverage under the Alpha Phi Alpha Fraternity, Inc. insurance program. Failure to receive proper approval for these events will result in a $1,000 fine for the chapter. *PLEASE TYPE Chapter Name: Region: Eastern Midwest Southwestern
Key Number: Southern
Type: Alumni
College
District:
Western
District Director:
Type of Event:
Title of Event:
Date(s) of Event: Location / Address: City :
State:
Contact Person:
Contact Number: (
Contact Email:
Contact Fax:
Zip:
)
Please select how the certificate of insurance should be sent to the event chairperson Mail:
Fax:
Email:
Event Activities Description:
1. 2. 3. 4. 5. 6. 7.
Is there a co-sponsor? Yes No Not Applicable If Yes, Organization/Entity Name: Co –sponsor contact email address: Does the co-sponsor have insurance coverage? Yes No Not Applicable Planned Attendance: Estimated Attendance: Will there be any special construction, alteration or decorations for this event? Yes No Has this event been held in the past? How many times? Have there been any previous claims? Yes No Not Applicable If Yes please provide details of claim:
Phone: 410.554.0040 Fax: 410.554.0054 Email: insurance@apa1906.net
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Documented updated 10.06.2010
ALPHA PHI ALPHA FRATERNITY, INC. ®
2313 SAINT PAUL ST., BALTIMORE, MD 21218-5211 SPECIAL EVENT CHECKLIST
ADDITIONAL INSURED Additional Insured’s may be added to this policy. Such insured’s may be your landlord, college, university and/or proprietor from whom the chapter may be renting property for a special event. Please complete the Additional Insured Request Information below A charge of $100 will be assessed for all special event additional insured certificates and must be received by the Corporate Headquarters before the additional insured status is granted, if the request is made outside of the required time frame. Additional Insured’s Name: Address: City: Phone: Date and Time of Event: Description:
Type of Venue:
Club/ Night Spot
State:
Private Club
University/School Facility
Zip: Email Address:
Catering Venue/ Banquet Hall
Conference Center
Religious Venue
Sports Facility Museum
Other
Please answer the below questions and if any answer is “Yes” please include the documentation with this request; 1. Are Certificates of Insurance obtained from vendors? A. Liquor Legal Liability Yes B. General Liability Yes
No No
Not Applicable Not Applicable
2. Has vendor(s) provided proof of liquor license and temporary license to see on premises? Yes No Not Applicable 3. Is the fraternity named as an additional insured on all certificates from vendors? Yes No Not Applicable 4. Have applicable permits and permission been obtained from authorities: A. College/University Yes No B. Fund Raiser Yes No
Not Applicable Not Applicable
5. Has any written contract or agreement been signed for any part of this special event?* Yes No Not Applicable 6. Have you received any correspondence requesting proof of insurance for the event? Yes No Not Applicable Please select method of payment. This form must be sent in with full payment □ Certified Check □ Money Order □ Credit Card (Visa, AMEX, Master-card accepted) Type:_ _______________________________ Number: _ _______________________________ Expiration Date: _ _______________________Name: _ ______________________________ Signature: _______________________________ Date: ___ ________________________________ Phone: 410.554.0040 Fax: 410.554.0054 Email: insurance@apa1906.net
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Documented updated 10.06.2010
ALPHA PHI ALPHA FRATERNITY, INC. 速
2313 SAINT PAUL ST., BALTIMORE, MD 21218-5211 SPECIAL EVENT CHECKLIST
ALCOHOL Host liquor liability provides coverage when providing alcoholic beverages at no charge to those of legal drinking age. If you are found to be in the practice of manufacturing, distributing, selling, serving or furnishing alcoholic beverages, or if minors are involved, your coverage and protection is jeopardized.
1. Are Certificates of Insurance obtained from vendors? A. Liquor Legal Liability Yes B. General Liability Yes
No No
Not Applicable Not Applicable
2. Has vendor(s) provided proof of liquor license and temporary license to see on premises? Yes No Not Applicable 3. Is the fraternity named as an additional insured on all certificates from vendors? Yes No Not Applicable 4. Have applicable permits and permission been obtained from authorities: A. College/University Yes No Not Applicable B. Fund Raiser Yes No Not Applicable 5. Are security personnel, monitors, bar workers and/or vendors trained on how to deal with intoxicated guests and members? Yes No Not Applicable 6. Are wrist bands or other method provided for designating those who are not of legal drinking age? Yes No Not Applicable 7. Are all who are allowed to enter presenting I.D.? Yes No Not Applicable 8. Are those bringing alcoholic beverages giving a punch card showing alcoholic quantity and type? Yes No Not Applicable 9. Will intoxicated guest or members be served alcohol by bar workers? Yes No Not Applicable 10. Is there only one centralized location where alcohol and food is being served? Yes No Not Applicable 11. Is there a guest and member list at the door? Yes No Not Applicable 12. Are food and alternative non-alcoholic beverages available, visible and easily accessible? Yes No Not Applicable 13. Do you have a policy on confiscating keys from intoxicated guests? Yes No Not Applicable YOU MUST STOP SERVING ALCHOL AT LEAST ONE HOUR BEFORE EVENT ENDS
Phone: 410.554.0040 Fax: 410.554.0054 Email: insurance@apa1906.net
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Documented updated 10.06.2010
ALPHA PHI ALPHA FRATERNITY, INC. ®
2313 SAINT PAUL ST., BALTIMORE, MD 21218-5211 SPECIAL EVENT CHECKLIST
SECURITY 1.
Who is responsible for security?
2.
Type of security consists of: (If combination, please select which two make up the combination) Public Police Private Police Combination Paid
3.
Is there a security guard? Yes No
Not Applicable
4.
Does security guard check for weapons? Yes No Not Applicable
5.
Are security personnel trained on preventing illegal drug use? Yes No Not Applicable
6.
Are monitors and security personnel trained on preventing disorderly conduct or hazing? Yes No Not Applicable
7.
Are members or guest hand stamped if they want to leave and return to party? Yes No Not Applicable
8. 9.
Is smoking permitted at event? Yes No
Not Applicable
10. If yes, is there a designated smoking area? Yes No Not Applicable 11. Has event facility been inspected to ensure that it complies with applicable federal, state and local safety and fire codes? Yes No Not Applicable 12. Are guests and members informed of emergency evacuation routes? Yes No Not Applicable 13. Is there one well lit entrance that is controlled and monitored? Yes No Not Applicable 14. Are security personnel and/or monitors trained on preventing sexual abuse and harassment? Yes No Not Applicable
TRANSPORTATION Whenever chapters or members are transporting special event attendees, personal vehicles should not be used as they are not covered. Chapters should be encouraged to engage a licensed third party transportation vendor who will provide professional drivers. The transportation company assumes liability during the ride and removes the responsibility and risk from Alpha Phi Alpha Fraternity, Inc. Is transportation (taxi, Safe Rides, Sober Rides, exc.) available for guest who need or request it? Yes No Not Applicable Phone: 410.554.0040 Fax: 410.554.0054 Email: insurance@apa1906.net
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Documented updated 10.06.2010
ALPHA PHI ALPHA FRATERNITY, INC. ®
2313 SAINT PAUL ST., BALTIMORE, MD 21218-5211 SPECIAL EVENT CHECKLIST
AUTHORIZING OFFICERS *President:
Signature:
Date:
Treasurer:
Signature:
Date:
Vice President:
Signature:
Date:
Risk Management Officer:
Signature:
Date:
*Event Chairman
Signature:
Date:
*Advisor (College Chapters):
Signature:
Date:
* Required Signatures – Checklist will be returned and not processed if all required signatures are not listed. DISCLAIMER This questionnaire is being used to assist the chapter in having a safe event. DID YOU REMEMBER TO? Get all required signatures Include all additional insured to be included on the policy (if applicable) Indicate how the certificate of insurance should be returned to the chairperson Present a complete and professional form Include copy of flier/promotional materials Please return this Special Event Checklist to the Corporate Headquarters (insurance@apa1906.net) no later than three weeks (21 days) prior to the event. Forms received the week of the event will NOT be processed. Failure to submit this form within the appropriate time frame will result in the certificate not being processed in time for the event and will be subject to a late processing fee. Waiver forms should be signed by the participants involved in athletic events, however the Chapter keeps the waiver forms for their records and do not have to forward them with the Checklist. Please review the Insurance Manual on at http://apa1906.net for additional questions.
Phone: 410.554.0040 Fax: 410.554.0054 Email: insurance@apa1906.net
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Documented updated 10.06.2010