ASCE EVENT QUESTIONNAIRE

Organization:

Mailing Address:

Contact Person:

Email Address:

Daytime Phone #: Fax #

1. Name/Address Certificate Holder:

2. Type of Event: (brief description and date)

3, Additional Insured wording, if any:

4. Instructions for mailing (i.e., original and copy to insured or original to certificate holder
and copy to insured)

SIGNED: Date:

Please complete and fax to:

Patti Loftis
Armfield, Harrison & Thomas
(703) 771-1852 (fax)

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NOTES:

* If a contract or lease has been signed, please attach it.

* Liquor Law liability coverage is not provided by your insurance policy. It must be arranged for separately and
at an additional cost. It may also be required that a temporary liquor license be obtained from your local
jurisdiction. For clarification purposes, Host Liquor differs from Liquor Law Liability in that the former applies
only to liability which arises from the giving or serving of alcoholic beverages without receiving any form of
remuneration. If you charge for alcoholic beverages or receive any percentage of receipts from the sale of
such beverages, Host Liquor Liability coverage does not apply and you must purchase Liquor Law Liability
coverage. This coverage, as you may be aware, is generally quite costly.
Χ This form must be completed at least 6 weeks prior to the event.