Liquor Liability
Fields marked (*) are mandatory.
General Information
Name of Business
Contact Name
Mailing Address:
City
State
Zip
Business Phone:
Fax
Best Time To Call
Contact Email Address
About Your Business
Location Address
City
State
Zip
How Long at This Location (years)
Years in Business
Name On License
Effective Date Requested
Expiration Date
Type of Operation
Tavern or bar without entertainment and annual
alcohol beverage receipts over $250,000
Tavern or bar with entertainment nightclub
Tavern or bar without entertainment and annual
alcohol receipts under $250,000
Restaurant (over 50% food), hotel, motel, or
private club that serves food
Private Club (no food)
Package liquor store, convenience store or gas
station
Manufacturer, wholesaler, or distributor
Special event (include supplemental application)
If Other
Miscellaneous Information
Do you dispense or pro vide alcoholic beverages for any events off-premises?
If Yes, describe
Name of person who keeps the books
Phone
Sales Information (Past 12 months)
Estimated Sales
Gross Sales Other
Gross Alcohol Sales
Sales Information (Next 12 months)
Estimated Sales
Gross Sales Other
Gross Alcohol Sales
Coverage Information
Primary Limits Desired
Each Common Cause
Aggregate
Prior Policy Limits
Previous Coverage Information
Previous Liquor Liability Carrier
Premium
Limits
Policy Number
Effective Dates
Underwriting Information
LIABILITY
Seating Capacity
Dining Room
Bar
Outside Deck/Patio
Other
Does your establishment have any of the following (check all that apply)
Pinball Machines
How Many
Days Per Week
Video Games
How Many
Days Per Week
Pool Tables
How Many
Days Per Week
Juke box
Dock/Deck Area
Other
Does your establishment offer any entertainment (check all that apply)
Rock & Roll
nights per week
Disco
nights per week
Band
nights per week
Country Western
nights per week
Piano
nights per week
Juke Box
nights per week
Topless Girls
nights per week
Dancing
nights per week
HappyHour
nights per week
Other
Miscellaneous Information
Hours of Operation
Sunday
From
To
Closed
Closed Part of Day
Monday
From
To
Closed
Closed Part of Day
Tuesday
From
To
Closed
Closed Part of Day
Wednesday
From
To
Closed
Closed Part of Day
Thursday
From
To
Closed
Closed Part of Day
Friday
From
To
Closed
Closed Part of Day
Saturday
From
To
Closed
Closed Part of Day
Employee Information
Number of employees (per shift):
1st Shift
2nd Shift
3rd Shift
Number of bouncers / security
Bouncers
Security
Current / Previous Insuror
Current/Previous Insurance Company
Policy Number
Expires
Premium for package policy
Limits
Is general liability coverage carried
Applicant ever had insurance cancelled or non-renewed
If yes, provide details
Applicant of any other owner, partner or licensee
ever had a liquor license revoked or suspended
If yes, provide details
Additional Comments
Additional Comments