Insurance Liquor Liability Application

INSURANCE LIQUOR LIABILITY APPLICATION

Applicant / Insured Information

Business Entity Type: Individual Partnership Corporation LLC Other

Business / Premises Information

Hours of Operation:   Seating Capacity:   Avg % Revenue from Alcohol:

Policy Details Requested

Coverage Selection

Select coverages requested (check all that apply):

Liquor Liability (Host/Server Liability for sale/service of alcoholic beverages)
Premises Liability
Assault & Battery (limited sublimit)
Product Liability
Incidental Contractual Liability
Additional Insured Endorsement requested

Operations, Controls and Risk Management

Do you employ security personnel or licensed bouncers?   Yes No   If yes, number of guards:

Do staff receive formal alcohol server training (e.g., certification)?   Yes No   If yes, training provider:

Exclusions & Limitations (Acknowledgment)

The applicant acknowledges that standard policy exclusions may apply, including but not limited to: intentional acts causing injury, acts of war, criminal conduct by insureds, and punitive damages where not insurable by law. Indicate acceptance of these standard exclusions:

I acknowledge and accept standard policy exclusions as described above.

Do you request any exclusion waivers or endorsements that would modify standard exclusions?   Yes No   If yes, describe:

Claims / Loss History (Past 5 Years)

Any claims, incidents or liquor-related losses in the past five (5) years?   Yes No

Beneficiary / Payee Designation for Proceeds

Designate beneficiary(ies) for any policy proceeds or settlement disbursements (if different from named insured). Percentages must total 100%.

Documentation Checklist

Please attach copies of the following documents where applicable (check items attached):

Copy of current liquor license
Sample menu listing alcoholic beverages
Security plan / capacity control procedures
Alcohol server training certificates
Past incident reports / claim files
Premises floor plan and seating layout

Declaration and Certification

By signing below, the applicant certifies that all information provided in this application is true, accurate and complete to the best of the applicant's knowledge. The applicant understands that this application, including any attachments and materials submitted in connection herewith, will become the basis for any policy issued and is a representation upon which the insurer will rely in determining eligibility, coverage terms and premium. The applicant further acknowledges that any material misstatement, omission or concealment of fact may render coverage voidable or allow the insurer to deny claims and/or rescind the policy.

The applicant authorizes the insurer and its representatives to obtain claim and underwriting information, to inspect the premises, and to verify any statements or documentation provided. The insurer's acceptance of this application is subject to underwriting review and issuance of a policy form and endorsements that define coverage, conditions, limitations and exclusions.

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