HomeMy WebLinkAboutTUP23-001412NOTS0065TX (01-21)
Scottsdale Insurance Company
IMPORTANT NOTICE—TEXAS
Have a complaint or need help?
If you have a problem with a claim or your premium, call
your insurance company first. If you can’t work out the is-
sue, the Texas Department of Insurance may be able to
help.
Even if you file a complaint with the Texas Department of
Insurance, you should also file a complaint or appeal
through your insurance company. If you don’t, you may
lose your right to appeal.
Scottsdale Insurance Company
To get information or file a complaint with your insurance
company:
Call: Scottsdale Insurance Company
Toll-free: 1-800-423-7675
Online: www.nationwideexcessandsurplus.com.
Email: ESSContactUs@Nationwide.com
Mail: Scottsdale Insurance Company
18700 North Hayden Road
Scottsdale, Arizona 85255
The Texas Department of Insurance
To get help with an insurance questions or file a complaint
with the state:
Call with a question:1-800-252-3439
File a complaint: http://www.tdi.texas.gov
Email: ConsumerProtection@tdi.texas.gov
Mail: MC 111-1A
P.O. Box 149091
Austin, Texas 78714-9091
AVISO IMPORTANTE—TEXAS
¿Tiene una queja o necesita ayuda?
Si tiene un problema con una reclamación o con su prima
de seguro, llame primero a su compañía de seguros. Si no
puede resolver el problema, es posible que el Departa-
mento de Seguros de Texas (Texas Department of Insur-
ance, por su nombre en inglés) pueda ayudar.
Aun si usted presenta una queja ante el Departamento de
Seguros de Texas, también debe presentar una queja a
través del proceso de quejas or de apelaciones de su com-
pañía de seguros. Si no lo hace, podría perder su derecho
para apelar.
Scottsdale Insurance Company
Para obtener informatión o para presentar una queja ante
su compañía de seguros:
Llame a: Scottsdale Insurance Company
Teléfono gratuito: 1-800-423-7675
En Línea: www.nationwideexcessandsurplus.com.
Correro Electrónico: ESSContactUs@Nationwide.com
Dirección Postal: Scottsdale Insurance Company
18700 North Hayden Road
Scottsdale, Arizona 85255
El Departamento de Seguros de Texas
Para obtener ayuda con una pregunta relacionada con los
seguros o para presentar una queja ante el estado:
Llame con sus preguntas al: 1-800-252-3439
Presenta una queja en: www.tdi.texas.gov
Correro Electrónico: ConsumerProtection@tdi.texas.gov
Dirección Postal: MC 111-1A
P.O. Box 149091
Austin, TX 78714-9091
04/11/2023 11:12 AM Page 1 of 4
Commercial Insurance Binder
To:
Contact Name:
Contact Email:
Contact Phone:
From:Amwins Brokerage (Dallas, TX)
Address:5910 N Central Expy Ste 500 Dallas TX
75206-1107
Policy Number: CPS7770001
Underwritten By: SCOTTSDALE INSURANCE COMPANY A.M. Best rated A+ (Superior), FSC XV
Minimum Earned: 100%Minimum and Advance
Premium: 100%
Thank you for your request to bind coverage for the below referenced account. We appreciate your business and are pleased
to bind the following terms.
If the policy is cancelled at the insured's request, including non-payment of premium, there will be a minimum earned
premium retained by us. If a policy or inspection fee is applicable to this policy, the fees are fully earned. No flat
cancellations.
At the close of each audit period, we will compute the earned premium for that period. If the earned premium is greater than
the advance premium paid, an audit premium will be due. There will be no returned premium upon Audit if the estimated
exposure is less than shown, unless the Minimum and Advance Premium is less than 100%.
Applicant Name:HIGHLAND ARTS & ATHLETICS
Policy Period:04/21/2023 To 04/24/2023
Policy Number:CPS7770001
Agent Reference Number:
Renewal of #:NEW
Premium Summary
LIABILITY $1,280
Sub Total Premium:$1,280
Policy Fee $200.00
Surplus Lines Tax $71.78
Stamp Fee $1.11
Grand Total:$1,552.89
Terrorism: Terrorism coverage has been rejected for an additional premium of $64.00 plus applicable taxes and fees.
Signed rejection required at binding.
04/11/2023 11:12 AM Page 2 of 4
Commercial Liability Coverage
Limits
General Aggregate $2,000,000
Products/Completed Operations Aggregate $2,000,000
Personal and Advertising Injury $1,000,000
Per Occurrence $1,000,000
Damage to Premises Rented to You $100,000
Medical Payments $5,000
Deductible $0 BI/PD/PA PER CLAIMANT
Liability Rating Classifications and Premium
Loc #/
Bldg #
Program /
ISO Class Code Description Exposure Prem /
Prod Rate
Prem / Prod
Premium
3000 MEADOWMERE PARK GRAPEVINE TX 76051
1 / 1 CT 10378 FAIRS - OTHER THAN
NOT-FOR-PROFIT+
START DATE:04/21/2023
END DATE:04/24/2023
4,000 / PER
PERSON /
EACH
$.32
INCL
$1,280
INCL
† + PRODUCTS/COMPLETED OPERATIONS ARE SUBJECT TO THE GENERAL AGGREGATE LIMIT
Final Liability Premium:$1,280
04/11/2023 11:12 AM Page 3 of 4
Forms and Endorsements
Common Policy
NOTS0065TX 01-21 IMPORTANT NOTICE-TEXAS
NOTS0079TX 04-09 TEXAS REQUIRED NOTICE
NOTX0178CW 03-16 CLAIM REPORTING INFORMATION
NOTX0423CW 12-20 POLICYHOLDER DISCLOSURE - NOTICE OF TERRORISM INSURANCE COVERAGE
UTS-COVPG 03-21 COVER PAGE
OPS-D-1-0117 01-21 COMMON POLICY DECLARATIONS
UTS-126L 10-93 SCHEDULE OF TAXES, SURCHARGES OR FEES
UTS-SP-2 12-95 SCHEDULE OF FORMS AND ENDORSEMENTS
UTS-SP-3 08-96 SCHEDULE OF LOCATIONS
IL 00 17 11-98 COMMON POLICY CONDITIONS
UTS-496 06-19 MINIMUM EARNED CANCELLATION PREMIUM
UTS-9g 06-22 SERVICE OF SUIT CLAUSE
Commercial Liability
CLS-SD-1L 08-01 COMMERCIAL GENERAL LIABILITY COVERAGE PART SUPPLEMENTAL DECLARATIONS
CLS-SP-1L 10-93 COMMERCIAL GENERAL LIABILITY COVERAGE PART EXTENSION OF SUPPLEMENTAL
DECLARATIONS
CG 00 01 04-13 COMMERCIAL GENERAL LIABILITY COVERAGE FORM
CG 21 06 05-14 EXCLUSION-ACCESS OR DISCLOSURE OF CONFIDENTIAL OR PERSONAL INFORMATION AND
DATA-RELATED LIABILITY-WITH LIMITED BODILY INJURY EXCEPTION
CG 21 16 04-13 EXCLUSION-DESIGNATED PROFESSIONAL SERVICES
CG 21 32 05-09 COMMUNICABLE DISEASE EXCLUSION
CG 21 44 04-17 LIMITATION OF COVERAGE TO DESIGNATED PREMISES, PROJECT OR OPERATION
CG 21 47 12-07 EMPLOYMENT-RELATED PRACTICES EXCLUSION
CG 21 67 12-04 FUNGI OR BACTERIA EXCLUSION
CG 21 73 01-15 EXCLUSION OF CERTIFIED ACTS OF TERRORISM
CG 24 26 04-13 AMENDMENT OF INSURED CONTRACT DEFINITION
CG 40 12 12-19 EXCLUSION - ALL HAZARDS IN CONNECTION WITH AN ELECTRONIC SMOKING DEVICE, ITS
VAPOR, COMPONENT PARTS, EQUIPMENT AND ACCESSORIES
CG 40 15 12-20 CANNABIS EXCLUSION WITH HEMP EXCEPTION
GLS-106s 12-13 TOTAL LIQUOR LIABILITY EXCLUSION
GLS-152s 08-16 AMENDMENT TO OTHER INSURANCE CONDITION
GLS-271s 08-04 AMUSEMENT RIDE EXCLUSION
GLS-278s 01-06 INJURY TO WORKER EXCLUSION
GLS-289s 11-07 KNOWN INJURY OR DAMAGE EXCLUSION-PERSONAL AND ADVERTISING INJURY
GLS-341s 08-12 HYDRAULIC FRACTURING EXCLUSION
04/11/2023 11:12 AM Page 4 of 4
Forms and Endorsements
GLS-457s 10-14 AIRCRAFT EXCLUSION
GLS-47s 10-07 MINIMUM AND ADVANCE PREMIUM ENDORSEMENT
GLS-570 07-21 CONTRACTORS SPECIAL CONDITIONS
GLS-5s 04-08 SPECIAL EVENT PARTICIPANT EXCLUSION
GLS-623 10-21 TOTAL ASSAULT AND/OR BATTERY EXCLUSION
GLS-666 06-22 PFC/PFAS EXCLUSION
GLS-74s 09-05 AMENDMENT OF CONDITIONS
IL 00 21 09-08 NUCLEAR ENERGY LIABILITY EXCLUSION ENDORSEMENT
IL 01 68 03-12 TEXAS CHANGES-DUTIES
UTS-230g-TX 09-94 PROMPT PAYMENT OF CLAIMS-TEXAS
UTS-267g 05-98 LEAD CONTAMINATION EXCLUSION
UTS-365s 02-09 AMENDMENT OF NONPAYMENT CANCELLATION CONDITION
UTS-428g 11-12 PREMIUM AUDIT
UTS-610 06-22 ASBESTOS EXCLUSION
UTS-611 07-22 EXCLUSION—BIOMETRIC INFORMATION
UTS-74g 08-95 PUNITIVE OR EXEMPLARY DAMAGE EXCLUSION
09/15/16
Tarrant County Public Health Department
Environmental Health Promotion
1101 S. Main Street, Room 2300
Fort Worth, Texas 76104
Phone: (817) 321-4960 Fax: (817) 321-4961
Temporary Food Establishment Permit Application
PLEASE COMPLETE & RETURN THIS FORM WITH FEE FOR EACH STAND AT LEAST 10 DAYS BEFORE THE START OF THE EVENT.
Fee Information: (submit one of the following)
1) $35.00 for each stand or unit. We are unable to accept credit/debit cards by phone or online.
2) IRS 501 (c) (3) official recognition documentation for tax exempt charitable organizations.
General Event Information:
3) Name of Event: ___________________________________________________________
4) Date(s) of Event: __________________________________________________________
5) Hours of Operation: ________________________________________________________
6) Location of Event: _________________________________________________________
7) Event Coordinator:
Name: ___________________________________________ Phone: ________________
Address: ________________________________________________________________
Applicant Information:
8) Your Organization/Business Name: ___________________________________________
9) Applicant’s Name: _________________________________________________________
Address: ________________________________________________________________
City: ____________________________ State: _________________ Zip: ____________
Business Phone: _______________________ Home Phone: _______________________
Mobile Phone: _________________________ Fax: ______________________________
Email: __________________________________________________________________
10) Does this business have a current mobile food unit or pushcart permit from the Tarrant
County Health Department? [ ] Yes [ ] No
If yes, what is the permit type and site number? __________________________________
Note: Vendors with these types of health permits are not required to pay the permit fee for
a temporary food service establishment.
11) List full menu to be served at the event: ________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Grapevine Lake Celtic Heritage Festival & Highland Games
April 22, 2023
8:00 a.m. - 6:00 p.m.
3000 Meadowmere Lane, Grapevine, Texas 76051
Highland Arts & Athletics 469-742-1159
1805 Touch Gold Court, Rowlett, Texas 75088
Highland Arts & Athletics
Susan Berry
Texas 75088Rowlett
1805 Touch Gold Court
469-742-1159 469-742-1159
469-742-1159 na
susanberry@highlandartsandathletics.org
na
Beer Garden - canned and draft beer
Merchandise Tent - bottled water, sodas, gatorade
09/15/16
Temporary Food Establishment Permit Application Page 2
Tarrant County Public Health Department
12) Where will the food be purchased/obtained from: ________________________________
_______________________________________________________________________
13) Will any foods be prepared prior to the start of the event? [ ] Yes [ ] No
If yes, where will the food be prepared? _______________________________________
_______________________________________________________________________
If answering yes to question 11, all foods prepared prior to the event are required to be
made in an approved and permitted facility. A copy of the Food Establishment Permit and
signed Commissary Agreement (attached) are required for approval of this application.
Applications submitted without this information will be returned.
Has a copy of the Food Establishment Permit and signed Commissary Agreement been
included with this application? [ ] Yes [ ] No [ ] N/A
14) Will frozen foods be thawed at the event? [ ] Yes [ ] No
If yes, describe process/method to be used: ____________________________________
15) How will any leftovers of cooked food be handled at the end of the day?
_______________________________________________________________________
16) How will food temperatures be checked during the event? __________________________
17) Describe equipment used at the event for:
a) Cold holding: _________________________________________________________
b) Hot holding: _________________________________________________________
c) Cooking/Reheating: ___________________________________________________
18) Describe hand washing facilities inside your temporary food establishment:
[ ] Plumbed Sink [ ] Gravity Flow Set-up
19) Describe utensil washing facilities inside your temporary food establishment:
[ ] 3 Compartment Sink [ ] 3 Basin Set-up
20) How will hot water be made available for the hand wash and utensil washing stations?
_______________________________________________________________________
21) What type of sanitizer will be used at the event? _________________________________
22) How will potable water be obtained during the event? _____________________________
23) How will waste water from hand & utensil washing be disposed? ____________________
_______________________________________________________________________
Form completed by: ___________________________________________________________
Name/Title Date
Beer is purchased from brewerys.
Water, Gatorade and Sodas will be purchased from Costco.
na
na
na
na
na
na
none
na
none
na
na
Susan Berry 04/06/2023
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M
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R
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T
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S
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A
N
D
:
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l
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a
s
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l
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h
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w
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h
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.
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.
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.
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T
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R
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&
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W
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l
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.
UT
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S
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:
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:
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(
3
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;
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