Liquer Liability App

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Century Surety Group Liquor Liability Application

Century Surety Group Liquor Liability Application

Name of Applicant (include dba):
2. Mailing Address:
3. Location Address:
4. Applicant is: Individual Partnership Corporation LLC Other
If other, explain:
5. Location is (NOTE: If more than one of the above applies at this location, then "x" each applicable box): Bar or Tavern Caterer Country Club Mini Mart without Gas Mini Mart with Gas Motel/Hotel Package Store Private Club Restaurant Special Event (short term) Sprots Bar Supermarket or Grocery Store Other
If other, explain:
6. If private club, indicate type (be specific) and purpose:
7. Type(s) of Liquor License? On Sale Off Sale Beer Wine Liquor
8. Show Hours and Days of Operation:
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
9. Show Receipts for Estimated Next 12 Months & Last 12 Months:
a. Alcoholic Beverages:
b. Food
c. Other
10. Indicate type of area where you are located: Commercial (Non-Industrial) Downtown Industrial Residential Resort Rural Suburban
11. Do you have any of the following? Athletic Contests/Events Bouncers Comedy Shows Dance Floor Dart Board Disc Jockey Doorman Exotic Dancers ID Checker Live Music Mechanical Ride Movies Pinball Machines Pool Tables Shuffleboard Video Games Nude Dancers/Reviews Firearms
Or either of the following: Security Guards (employees) Security Guards (independent)*
*Do independent contractors carry liability insurance and provide certificates? Yes No
If you x'd any of the above boxes, explain in detail (be specific about the type of music provided, etc.):
Night Clubs (or any risk where entertainment is a primary function) is only written on a claims made form.
12. Do you sponsor or provide any of the following? Ladies Night 2 for 1 Drinks Singles Night Drinks Special Doubles for Single Prices Free Alcoholic Drinks
13. Percent of patrons arriving and departing by automobile?
14. Maximum number of employees (including owners and managers) on duty at any one time?
15. Maximum capacity of premises allowed by law?
16. Maximum number of patrons on premises at any one time?
17. Average number of patrons on premises at any one time?
Predominate age range of patrons? 21 - 35 26 - 35 Over 35
19. Do you allow anyone under 21 on your premises? Yes No
If yes, explain:
20a. Have you or this establishment ever been charged, cited or fined by ABC commission or other governmental regulator? Yes No
If yes, explain:
20b. Have you or this establishment ever had its alcohol beverage license suspended or revoked? Yes No
20c. Number of bartenders?
Number of other employees serving alcoholic beverages?
20d. Does this establishment have an alcohol awareness training program for the prevention of alcohol abuse? Yes No
If yes, complete the following:
1. Are all servers trained within sixty (60) days of employment? Yes No
2. Do you provide written policies and procedures to employees regarding minimum service to minors and intoxicated persons? Yes No
3. Name of awareness program:
4. Do you provide free rides home to intoxicated patrons? Yes No
If yes, explain:
21. Prior Insurance/Loss History (show liquor liability insurer(s) for past three (3) years):
Record Year, Insurance Company, Limits, and Policy Number (in that order)
1:
2:
3:
Have you had any liquor liability claims (insured or uninsured) in the past three (3) years? Yes No
If yes, list them below:
Record Year, Insurance Company, Limits, and Policy Number (in that order)
1:
2:
3:
22. Show insurer, policy term and limits for general liability coverage (limits must equal or be greater than the liquor liability limits)
23. Was your last liability coverage on a claims made coverage form? Yes No
Is this application for claims made form? Yes No
If yes, is Prior Acts Coverage desired? Yes No
If yes, attach a copy of current declarations page showing retroactive date.
24. Do you have knowledge of any injury or accident which might have been caused by the serving of alcoholic beverages from your establishment which occured after the requested effective date and prior to the completion of this application? Yes No
If yes, explain in detail including name of injured party and date of incident:
Requested limits (in thousands) 100/100 100/300 300/300 500/500 Other
If other, please elaborate:
Requested Deductible*: $500 $1,000 $2,500 $5,000
*Deductible applies per claim including defense expense for claims.
Requested policy term:
Contact Person:
Telephone #:
The Claims Made Liquor Liability form only provides coverage for injury which occurs after the retroactive date (and which you had no knowledge of prior to the effective date of this policy) shown in the policy (see #23 of this application).
In addition, they must have been reported (in writing) to the insurance company during the coverage period of this policy and I fully understand this limitaiton.
I declare that the above statements and particulars are true and that no fact have been suppressed or misstated and that this application form is recognized to be the basis of any policy of insurance which may be issued by the Company.
The completion of this application does not bind the company to sell, and the misstatements of facts may void your coverage.
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Applicant:
Signature:
Date:
Producer:
Producer Signature:
email