EmailMe Form - Liquor Liability Coverage

Applicant's Legal Name *

Doing Business As *

What type of Liquor License does the applicant have? *

What is the applicant's Liquor License Number? *

Location Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Mailing Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Web Site

What is the Form of the business?

Number of Locations to be insured? *

Fill out this form again for each additional premises

Please give a Description of Operations *

What Year did the applicant start business at this location? *

MM / DD / YYYY

What are your annual Food Sales? *

$ Dollars . Cents

What are your annual Alcohol Sales-On Premises Consumption? *

$ Dollars . Cents

What are your annual Alcohol Sales-Off Premises Consumption? *

$ Dollars . Cents

What are your annual additional other sales, if any? *

$ Dollars . Cents

Please describe if there are other sales

What limits of liability are you looking for? *

What is the latest hour of operation? *

HH : MM AM/PM

What time does the sale of alcohol cease? *

HH : MM AM/PM

Does the applicant feature any live entertainment? *

Adult Entertainment/Exotic Dancing? *

Number of times per week?

Bands with 3 or more members? *

Number of times per week?

DJ with Dancing? *

Number of times per week?

Banquet Entertainment by applicant? *

Number of times per week?

Other types of Entertainment? *

Number of times per week?

If other types of Entertainment are provided, please describe.

Does the applicant ever employ bouncers, security, or door-persons? *

Are all alcohol-serving employees certified in a Formal Alcohol Training Course? *

If yes, what course and how often?

What is the average age of clientele at this establishment? *

Does the establishment utilize an identification scanner on all patrons regardless of age? *

Is BYOB (Bring Your Own Bottle) permitted for other than banquet operations? *

What is the maximum occupancy of the establishment? *

Does the applicant offer on-premises tasting or sampling of alcoholic beverages? *

Are there any additional insureds required on the coverage? *

If yes, please give name, relationship to applicant, and full address

Has the applicant or any principal with controlling interest ever filed for bankruptcy in the last 12 months? *

Will the applicant maintain a valid liquor license, if required by law, prior to any selling, serving, or distribution of alcohol? *

Does the applicant ever sell alcohol away from the premises? *

If yes, please describe

Are employees permitted to consume alcohol while working during there hours of employment or shift? *

Does the applicant ever offer any of the following:

Bottle Service or set-up?

Drink specials/happy hours past 9:00PM?

Beer Pong or other drinking games?

More than two complimentary drinks per patron per day?

What is the lowest price offered for beer including any happy hours or specials? *

$ Dollars . Cents

What is the lowest price offered for liquor or wine including any happy hours or specials? *

$ Dollars . Cents

Are patrons under the legal drinking age allowed on the premises? *

Are patrons under the legal drinking age allowed on the premises past 11:00PM? *

Has the applicant had any reported liquor liability and/or assault or battery claims or notification of potential liquor liability and/or assault or battery claims at this location in the past 5 years? *

If yes, please provide dates, descriptions, total incurred losses or payments made, the current status of the claim, and measures taken to prevent future incidents

Does the applicant maintain General Liability Limits Equal to or higher than the amount of Liquor Liability being requested? *

Must be answered yes to obtain quote

Does the applicant know of any fines, citations, or violations of law or ordinance related to illegal activities or the sale of alcohol in the past 5 years at this location? *

If yes, please provide dates, descriptions of fines or citations, and measures taken to prevent future incidents

Within the past 5 years, has the applicant had any liquor liability coverage cancelled or non-renewed? *

If yes, please explain

This section is for Restaurants or Bars with Banquet Operations

Are only the applicant and it's authorized employees or members permitted to serve alcohol at all events where alcohol is present?

If persons serving alcohol are not the applicant or its authorized employees or members, are they required to carry liquor liability insurance with limits equal to or greater than the applicant's coverage as well as naming the applicant as an additional insured?

This section is for Fine Dining Establishments

Is the average entree price greater than $20.00?

Is the average entree price greater than $30.00?

Is the number of bottles on the wine list greater than 10?

This section is for Non-Profit Private, Fraternal or Social Clubs

Is the applicant a non-profit private, fraternal or social club?

Are same day memberships available?

Are members permitted to bring more than 3 guests per day?

Is self-service of alcohol by members permitted?

Are any single drinks sold for less than $.50?

Is BYOB permitted for banquet operations only?

Referring Agent

*This section is for Restaurants or Bars with Banquet Operations*

*This section is for Fine Dining Establishments*

*This section is for Non-Profit Private, Fraternal or Social Clubs*

This section is for Restaurants or Bars with Banquet Operations

This section is for Fine Dining Establishments

This section is for Non-Profit Private, Fraternal or Social Clubs