Rotary International
in Great Britain & Ireland

Bartlett
INSURANCE BROKERS

Rotary Event Insurance Referral Form
This checklist must be completed for any event which in not automatically covered under the RIBI Liability Insurance.

Rotary Club of:	District:	
Contact name:	Address:	
Email:	
	
Telephone:	
	
Full details of planned activity or event:
How many times have you held this event before, over what time period?

Date of event:	Duration:	
Venue for event:	Anticipated no. of attendees:	
Details of any special risks or concerns you as a club have for this event:
Please provide a copy of risk assessments that have been undertaken. A risk assessment form is available to download here if required.

Is cover required for Cancellation and Abandonment Insurance (including Adverse Weather) - Cover will need to be arranged 28 days prior to the event.	YES/NO
nn	
If you are organising a Firework Display are you using a Professional Firework Company?	YES/NO
nn	

Have you obtained written confirmation from Third Party Organisations attending the event, that they have Public Liability Insurance in force?
Have you as a club sought permission / advice from any outside agencies regarding the event i.e. Council, Police, Fire Brigade, St Johns Ambulance? Please give details:

YES/NO
n

YES/NO

Do you require cover for any equipment borrowed or hired for the event? If yes, then please provide the following details:
Description of equipment: Replacement cost of equipment: Security measures of left overnight: Dates cover is required:

YES/NO

Is additional money cover required over and above the standard RIBI limits (please refer to the insurance guide).
If yes, please give full details of the limits required and procedures for the transit and where money will be kept until it is banked.

YES/NO

Has your club been asked to sign any agreement for this event?
If yes, please send a copy of the agreement to Bartlett for approval before signing.

YES/NO
DD

Signed:	Office:	
Print name:	Date:	
When complete this form should be sent to:
Bartlett Insurance Brokers
Broadway Hall
Horsforth
Leeds, LS184RS
Facsimile Number: 0113 258 5081
E-Mail: RIBI@bartlettqroup.com