Insurance Liquor Liability Renewal Form

INSURANCE LIQUOR LIABILITY RENEWAL FORM

Policy Renewal Information

Policy Number:    Current Carrier:

Current Policy Period: From to    Requested Renewal Effective Date:

Applicant / Insured Information

Contact Phone:    Email:    Date of Birth (owner/principal):

Business & Operations

Liquor License Number:    Issuing State:    Date Issued:

Seating Capacity:    Average Weekly Hours of Operation:    Percent of Gross Receipts from Alcoholic Beverage Sales:

Coverage & Limits Requested

Select coverages requested (check all that apply):

 Dram Shop Liability (third-party alcohol liability)

 Assault & Battery Endorsement

 Off-Premises / Catering Coverage for hosted events

 Hired Security Liability

Requested Deductible:    Estimated Annual Premium:

Claims / Loss History (Past Policy Period)

Any liquor liability claims, incidents, or suits during the past 12 months?    Yes    No

Exclusions & Acknowledgments

Applicant acknowledges that coverage will be subject to policy terms, conditions, limitations and exclusions which commonly include but are not limited to:

• Claims arising from intentional or criminal acts by the insured or insured's employees.
• Claims arising from sales to minors where the insured knowingly violated law.
• Punitive damages where prohibited by law or excluded by endorsement.
• Liability for products not sold or provided by the insured (recall exclusion).

I acknowledge receipt of, and understand, the typical exclusions described above and certify that no facts have been withheld that would materially affect underwriting of liquor liability coverage.
 Applicant acknowledges and accepts these exclusions

Beneficiary / Additional Insured / Certificate Holder

Primary Certificate Holder / Additional Insured Name:

Relationship to Insured:    Percentage of Interest (if beneficiary):

Documentation Checklist

Please indicate documents attached with this renewal submission:

 Copy of current liquor license

 Loss runs / claims history

 Security plan and training records

 Incident and police reports (if any)

Declarations and Certification

The undersigned certifies that the information provided in this renewal form is true, complete and accurate to the best of their knowledge. The undersigned understands that any material misrepresentation, omission, or fraud may result in denial of coverage, cancellation of policy, or rescission as permitted by law. The undersigned authorizes the insurer and its representatives to obtain underwriting information, verify representations, and obtain loss history, including from prior carriers and law enforcement where required for underwriting review.

The applicant understands that coverage, limits, conditions and exclusions will be set forth in the policy and that this renewal application does not bind coverage until accepted and approved by the insurer in writing and premium is paid as required.

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