Applicant Is: Individual  Corporation   Partnership    Joint Venture   Limited Liability Company   Other 

ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE "NOT APPLICABLE"

A. Classification of risk:

Tavern   Disco   Bowling center Caterer   Off premises   On premises

Restaurant   Banquet facility   Membership club   Country club

Number of years in business:

B. Annual sales:

C. Are surrounding premises:

Downtown district   Residential/commercial   Rural   Shopping center   Waterfront

Industrial   Resort   Seasonal   Suburban Commercial

If waterfront, does applicant provide boat docking facilities for patrons?............................................ No Yes

If yes, how many docking spaces for boats?

D. Clientele:

Local residents   Families   Retirement community   College students   Seasonal residents

Median age of patrons:   18-25   25-30   30-40   40 and over

Are premises located near a college or university?............................................................................. No Yes

E. Entertainment:

Is there any live entertainment on premises?...................................................................................... No Yes

Number of times per week:

If yes, describe (include go-go dancers, topless, disco, exotic, female/male):

Is there dancing?.............................................................................................................................. No Yes

Number of times per week: Square footage of dance floor:

Does applicant have amusement devices?.......................................................................................... No Yes

Is there a minimum or cover charge?.................................................................................................. No Yes

Sports on premises?........................................................................................................................ No Yes

Sports sponsored off premises?........................................................................................................ No Yes

Does applicant sponsor any special events?...................................................................................... No Yes

F. General Information:

Are facilities available for use or rent for private parties, receptions, banquets or similar affairs?.............. No Yes

Does applicant advertise or promote "happy hour" or other events when drinks are sold at a lower

price than usual?............................................................................................................................. No Yes

Do you subscribe to a taxi or other service providing transportation home to apparently intoxicated
persons?........................................................................................................................................ No Yes

Number of years under current management: How many hours per day is applicant open?

Types of meals served:      Full meals   Short order

Maintenance of building is: Good Average Poor

Housekeeping is:               Good Average Poor

Square footage of bar/restaurant:

Does applicant have parking area?........................... No Yes    Is lot well lit?...................................... No Yes

In the past five years, has applicant been cited by the Liquor Control Commission?............................... No Yes

Are police records and background checks conducted on employees?................................................. No Yes

Number of bouncers or doormen:

Are security guards/bouncers/doormen employees or independent contractors?

If independent contractors, do they provide Certificates of Insurance and Additional Insured

Endorsements to the applicant?........................................................................................................ No Yes

Does applicant have Workers' Compensation coverage in force?........................................ No Yes

Total number of employees:

G. During the past three years, has any company ever canceled, declined or refused to issue similar insurance

       to the applicant? (Not applicable in Missouri)....................................................... No Yes

Previous Insurer and loss history: Indicate all claims or losses (regardless of fault and whether or not insured)

or occurrences that may give rise to claims for the prior three years.

 See loss run attached

H. Does applicant have other business ventures for which coverage is not requested?.................... No Yes

This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the information contained herein shall be the basis of the contract should a policy be issued.

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/We agree to submit records for audit by the Company upon termination or expiration of this policy for the determination of actual gross receipts during the coverage period.

APPLICANT’S NAME AND TITLE:

APPLICANT’S SIGNATURE:_____________________________________________________________ DATE:______________

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

PRODUCER’S SIGNATURE:_____________________________________________________________ DATE:______________