Commercial Insurance Underwriters, Inc. A Surplus Lines Agency www.ciusgf.com 901 E. Saint Louis St. #205 Springfield, MO. 65806-2537

 

Liquor Liability Application

 

(COMPLETE IN ADDITION TO ACORD GENERAL LIABILITY APPLICATION)

 

Applicant's Name		Agency Name
Address		Agent
		Address
Location #1
	Complete a separate application for each location.	Email
Web Site Address		Phone

 

PROPOSED EFFECTIVE DATE:  From   To 12:01 A.M., Standard Time at the address of the Applicant

 

PLEASE ANSWER ALL QUESTIONS

 

1. Type of risk: 

   

 

2. Type of ownership: Corporation Individual Partnership Other

 

3. Have you ever been assessed a fine for violation of a law concerning the sale of alcohol, or had

      your liquor license suspended?..................................................................................................... No Yes

If yes, when and why?

 

4. Name on liquor license: Type of liquor license:

 

5. Square foot area of establishment: (Maximum Occupancy: )

 

6.  Premises within city limits?............................................................................................................ No Yes

 

7. Have all servers been through any server training (tips, tops)?...................................................... No Yes

      Type of course:

How often required?

Ride home policy?............................................................................................................................ No Yes

 

8. Number of servers:

 

9. How often does the manager review liquor liability laws with employees (including penalties for serving

    intoxicated customers)?

 

10. Are procedures in place regulating the sale of alcohol to minors or those under the influence?.. No Yes

     If yes, describe:

     How is age of customer verified?

 

11. Type of clientele:  Area Residents    Area Workers    Tourists    College  Other:

 

12. Percent of clientele: Under 25 % 25-30 % Over 30 %

 

13. Type of area: Industrial or Commercial Residential Rural Other

   Located on or near college campus?............................................................................................. No Yes

 

14. How many years has the applicant been in business?

 

15. How many years has the applicant been at this location?

 

16. How many days per week is the location open?

 

17. What time does the location close? Hours of serving?

 

18.  Is there a cover charge?.............................................................................................................. No Yes

 If yes, what is the amount? $

 

19.  Do you have “Happy Hour” or 2-for-1 drink specials?................................................................. No Yes

 Is last call announced?.................................................................................................................. No Yes

 Are customers allowed more than one drink at last call?................................................................... No Yes

 

20.  Are patrons allowed to BYOB (Bring Your Own Booze)?............................................................. No Yes

 

21. Security Activities:

Bouncers	Doorman	Off Duty Police
Contracted Security Firms:	inside	outside	armed	unarmed

   Any firearms kept or carried on the premises?................................................................................ No Yes

 

22.  Are there procedures for handling violent or disruptive patrons?............................................... No Yes

 If yes, please describe?

  

 

23. Types of entertainment activities:

  Live Entertainment Type and how often?

  DJ Dance Floor Size: Juke Box

  Pool Table(s) Number:

  Electronic Games Type:

  Mechanical Devices Type:

Other activities that would include patron participation (such as: wrestling, boxing, volleyball, etc.):

   Special Promotions................................................................................................................... No Yes

   If yes, describe:

  

 

24. Estimated liquor receipts: $ Other receipts: $

 

25. Average price for:   beer $    wine $    liquor $

 

26. Percent of receipts for on-premises consumption: .........................................................................%

 

27. Percent of receipts for off-premises consumption: .........................................................................%

 

28. Estimated food receipts: $

 

29. Percentage of liquor receipts to total receipts: ..............................................................................%

 

30. Prior carrier: Policy number:

 

31. Has applicant had any claims or occurrences that may give rise to claims?............................... No Yes

If yes, give details:

 

32. Gentlemen’s clubs:

   Turnover rate for staff:

   Are servers/dancers in training? ...................................................................................................... No Yes

   Does applicant prohibit serving of alcohol after hours to their staff? ..................................................... No Yes

   Are clients allowed to purchase drinks for dancers/hostesses? .......................................................... No Yes

 

33. Manufacturer:

   Tours of Facility?............................................................................................................................ No Yes

   Free samples given?....................................................................................................................... No Yes

If yes, how is quantity controlled?

 

34. Distributor:

   Any sponsored events?................................................................................................................... No Yes

   If yes, describe:

  

   Policy for giving away alcoholic beverages by Sponsor? .................................................................... No Yes

If yes, describe:

 

35. Caterers:

   Are clients/guests allowed to mix their own drinks?........................................................................... No Yes

   Does caterer provide liquor or bartending service?.............................................................................. No Yes

 

FRAUD WARNING:

 

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

 

FRAUD WARNING (APPLICABLE IN TENNESSEE AND WASHINGTON):

 

It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

 

FRAUD WARNING APPLICABLE IN THE STATE OF NEW YORK:

 

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

 

I understand that Liquor Liability is a separate coverage part and the limits requested in this application apply solely to
liquor liability coverage and may differ from the General Liability limits afforded in my commercial package policy.

 

I further understand that the Company is relying upon statements I have made in this application as an inducement to provide insurance for Liquor Liability coverage.

 

APPLICANT’S NAME AND TITLE:

 

APPLICANT’S SIGNATURE: _______________________________________________________ Date:______________

 

(Must be signed by active owner, partner or executive officer)

 

PRODUCER’S SIGNATURE: _______________________________________________________ Date:______________

 

 

Before You Submit To Us, Make Sure You Fill in the RED Areas.  We Also Recommend Printing a Copy!!
TO COMPLETE YOUR APPLICATION, COMPLETE THESE TWO STEPS:
1.  Please select your Personal Lines Account Executive:	2.  Hit this Submit button.
New Business Abi Haase Amy Murfield Beth Bass Bridget Bogard Christin Dancy Kim Hampton Kim Moore Nicole Staudt Rachel Day	Submit