Scottsdale Insurance Company Columbus, Ohio 43215 Home Office: One Nationwide Plaza Adm. Office: 8877 North Gainey Center Drive Columbus, Ohio 43215 Scottsdale, Arizona 85258 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona Scottsdale Surplus Lines Insurance Company Adm. Office: 8877 North Gainey Center Drive Scottsdale Indemnity Company Scottsdale, Arizona 85258 Home Office: One Nationwide Plaza CLUB PROGRAM SUPPLEMENTAL APPLICATION (Complete in addition to the ACORD General Liability Application) Applicant’s Name: Agency Name: Location Address: Agent No.: Phone No.: PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE APPLICABLE” or N/A “NOT 1. Type of Club or Organization: a. Civic Service Social For Profit Not-For-Profit b. c. Athletic or Sports Equestrian Riding Political ATV, Motorcycle or Snowmobile Equestrian Polo Polo Automobile Exercise/Health Racquet Sports and Handball Beach Club Financial/Investing Snow Sports Business or Professional Gentlemen’s Club Social Services—Consulting Camping Hunting/Shooting Swimming Collegiate Fraternities or Sororities Medical Marijuana Water Polo Country or Golf Non-Collegiate Fraternity Water Sports Dating/Encounter Other—Describe: 2. Describe purpose/goals of your club/organization: 3. Are any buildings or premises owned or leased except for office purposes? Yes No Square If yes: footage you occupy. Square footage used for hall rental. Square footage you lease to others. 4. Number of members? Annual 5. Sources of Revenue: Membership fees or dues Donations Restaurant/Food sales Catering operations Liquor sales Hall rental Rental income from property leased to others
Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona Scottsdale Indemnity Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Surplus Lines Insurance Company Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 CLUB PROGRAM SUPPLEMENTAL APPLICATION (Complete in addition to the ACORD General Liability Application) Applicant’s Name: Location Address: Agency Name: Agent No.: Phone No.: PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” or N/A 1. Type of Club or Organization: a. Civic Service Social b. For Profit Not-For-Profit c. Athletic or Sports Equestrian Riding Political ATV, Motorcycle or Snowmobile Equestrian Polo Polo Automobile Exercise/Health Racquet Sports and Handball Beach Club Financial/Investing Snow Sports Business or Professional Gentlemen’s Club Social Services—Consulting Camping Hunting/Shooting Swimming Collegiate Fraternities or Sororities Medical Marijuana Water Polo Country or Golf Non-Collegiate Fraternity Water Sports Dating/Encounter Other—Describe: 2. Describe purpose/goals of your club/organization: 3. Are any buildings or premises owned or leased except for office purposes? Yes No If yes: Square footage you occupy. Square footage used for hall rental. Square footage you lease to others. 4. Number of members? 5. Annual Sources of Revenue: Membership fees or dues Donations Restaurant/Food sales Catering operations Liquor sales Hall rental Rental income from property leased to others
Club%20Program%20Supplemental%20Application.docx