NOTE:CATHOLICMUTUALMUSTRECEIVEAPPLICATION ATLEAST15DAYSPRIORTOEVENT.DONOT SUBMITAPPLICATIONSMORETHAN6MONTHSINADVANCE.

THECATHOLICDIOCESEOFHOUMA-THIBODAUX-0352

APPLICATIONFORSPECIALEVENTSCOVERAGE

CoverageLimit: $1,000,000CombinedSingleLimitBodilyInjuryandHostLiquorLiability,$500,000PropertyDamageLiability.

Includes: $100,000forDefenseCostsforSexualMisconduct,excludingovernightevents(seebelowforpurchaseoptions)

Coverageprovidedisperevent(notperclaim). Submissionofapplicationdoesnotbindcoverage-alleventsaresubjecttoapproval.

Coverageunderwrittenby: NationwideMutualInsuranceCompany;PolicyNo.onfilewithC.M.G.Agency,Inc.

CostofCoverage: $95PerEvent (OvernightStays-$125)

TOAVOIDDELAYORDENIALOFCOVERAGE,PLEASEENSURETHATEVERYFIELDISCOMPLETED.

NameofParishorInstitution:

DateofEvent:

(month – day – year)

Street (Physical) Address(NOP.O.BOXES): City/State:

PhoneNo.:

ZIPCode:

Type ofSpecialEvent(Example:weddingreception,anniv.party, etc.Ifit'saFUNDRAISER,bespecificaboutwhatisoccurring):

TimeofEvent:From__ To _

Lessee(AdditionalInsured)Information:

NameofSponsoringOrganizationorIndividualRequestingCoverage

Isthisanovernight event?

YesNo

(PleasePrintLesseeName(s)orOrganization)

Lessee(AdditionalInsured)ContactPerson:

Name:

Approx.NumberofParticipants:

IsFoodBeingServed?

YesNo

IsLiquorBeingServed?

Street Address: City/State:_ Telephone:

ZIP Code:

YesNo

Ifliquor istobesold(orcostincludedinticket price)and/oralicenseor permitisrequiredinorder foryoutoserveorfurnishalcohol,youmust obtain LIQUORLIABILITYcoveragebyseparateapplication.

Doesthiseventrequiretheadditionalcoverage? Yes No

Toreceiveapprovalnotificationpleaseprinte-mail(s):

{PleasePrint E-mail(s)Clearly)

COVERAGEDOES NOTAPPLYTOCERTAINEVENTS,SUCHAS,BUTNOTLIMITEDTO:

To Note:Ifliquorliabilitycoverage IsNOTpurchasedandanalcohol relatedclaim results,theclaim willbeexcludedifItIsdeterminedthat aliquor liabilitypolicyshouldhavebeenpurchased.

DEFENSECOSTSFORSEXUALMISCONDUCT FOROVERNIGHTEVENTS-$100,000LIMIT

Coveragedoesnotautomaticallyapplyforovernightevents,however, youhavetheoptiontopurchase thiscoveragebyseparateapplication.

Additionalchargemayapply.

•Anycarnivalevent

•Fireworksfireworksdisplays

Doyouwanttoapplyforthiscoverage?

YesNo

•Eventsinvolving'BYOB'(Bringyourownbottle)

•Eventsinvolvingpoolorlakeactivities

•Eventsinvolvingrecreationalvehicles

•Rap/Hip-Hop/Alternativemusic(non-religiousbands)

•Eventsorganizedoroperatedbyprofessionalpromoters/

performers

•Organizedsportingevents,includingtournaments camps (somesportingactivitiesareallowedandmustbepre­ approved).

•Eventswhereafeeoradmissionischarged,unlessallproceeds gotocharity

•PoliticalRallies

•Amusementrides,includingmechanicallyoperated devices,trampolines,reboundingdevices
ADDITIONALCHARGESWILLAPPLYFOR:

•Eventswhichexceed3daysinduration(chargeTBD)

•InflatableAmusementDevice(Mustbe pre-approved,picture required. Minimumchargeof$100perinflatableapplies; eachdeviceisunderwritten;chargeisdeterminedbysizeand potentialrisk.)

•Eventsthatexceed1,000inattendance(chargeTBD)

MAKECHECKPAYABLETO:

THECATHOLICDIOCESEOFHOUMA-THIBODAUX

RETURNWITHFORMTO:

THECATHOLICDIOCESEOFHOUMA-THIBODAUX P.O.BOX505

SCHRIEVER,LA 70395

Copyto:CATHOLICMUTUALGROUP

INTHE EVENTOFACLAIM,PLEASE CONTACTC.M.G.AGENCYCLAIMSDEPT: 800-228-6108

Person submitting this form: ______Contact #: ______

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