Insurance Liquor Application

INSURANCE LIQUOR APPLICATION

Applicant / Insured Information

Applicant Name:

Individual   Partnership   Corporation   LLC   Other:

Phone:    Email:

Federal Tax ID / SSN:

Date of Birth:

Policy Details Requested

Liquor Liability   Assault & Battery   General Liability (GL)   Property Coverage

Coverage Limit: $    Deductible: $    Estimated Annual Premium: $

Policy Period Requested: From to

Business Operations & Exposure

Liquor License Number:    Issuing Authority:

License Expiration Date:

Hours of Operation: Open   Close

Mon  Tue  Wed  Thu  Fri  Sat  Sun

Seating Capacity / Maximum Occupancy:    Indoor Seating:    Outdoor Seating:

Percentage of Sales from Alcoholic Beverage Sales:

Percentage of Sales from Food:

Live music  DJ  Karaoke  Televised sports  Other:

Security & Loss Control

Security Personnel on Premises: None   Contracted   In-house

Number of Security Personnel per Shift:    Armed Security: Yes   No

Do staff use ID verification or scanning on entry? Yes   No

Video Surveillance Coverage: Yes   No    If yes, recording retention period:

Regulatory, Claims & Loss History

Any convictions, suspensions, or disciplinary actions related to sale/service of alcohol in the past 5 years? Yes   No

Prior Liquor Liability Claims in last 5 years:    Last Claims Date:

Has any insurer cancelled, non-renewed or refused similar insurance in the last 5 years? Yes   No

Coverages, Endorsees & Beneficiary Information

Additional Insureds / Certificate Holder (name and address):

Relationship to Applicant:    Allocation Percentage:

Exclusions, Conditions & Declarations

The following are typical exclusions and apply unless expressly added by endorsement: claims arising from intentional acts or criminal conduct by insureds, sale of alcohol to minors knowingly, punitive damages where not insurable by law, liability arising from non-permitted events, and liabilities assumed under contracts except where provided by written endorsement. Applicant must initial to acknowledge review of exclusions.

Applicant Initials:

By signing below, Applicant represents that the statements and answers in this application are true and complete to the best of Applicant's knowledge and that no material information has been omitted. Applicant understands that this application, including all attachments and supplementary information, becomes a part of any policy issued and that coverage may be rescinded or denied if material misrepresentation or omission is discovered. Applicant authorizes the insurer to obtain underwriting, claim and loss information from prior insurers, law enforcement or licensing authorities as necessary to evaluate this application.

Applicant acknowledges that coverage is subject to the terms, conditions, limitations and exclusions of the policy issued and that premium and policy issuance are subject to underwriting approval.

Signature and Certification

The undersigned certifies that they are authorized to complete this application on behalf of the Applicant and that the information provided is true and complete.

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