APPLICATION FOR LIQUOR LIABILITY INSURANCE
Centrex Liquor Liability Program
1. Type of Application: New Renewal
Expiring Policy #: __________________________
Surplus Lines Producer: _________________________________________
City/State: _________________________________________
Contact: _________________________________________
2. Desired Policy Period From: _________________________ To: _____________________________
3. Limit Requested: $50,000 $100,000 $200,000 $300,000 $500,000 $1,000,000 Other: $_____________
4. Name of Applicant (show all names including legal and dba’s): ______________________________________________________________________________
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Applicant’s Mailing Address (city, state and zip):
________________________________________________________________________________________________________________________________
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Telephone #: ( ) ______________________ Applicant’s total years of experience in this business: ___________
5. Name of Location to be Insured: __________________________________________________________________________________________
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Location Street Address (city, state and zip): __________________________________________________________________________________________
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# of Locations to be Insured: ________ Telephone #: ( ) ______________________ Applicant’s years in business at this Location: _______
NOTE: Only 1 location per application except for retail store classes (attach Multi-Location Supplement).For Special Events, use Centrex Special Event Application.
6. If a Liquor Liability policy is issued, it will cover only the designated Insured Location(s) which will be subject to inspection and audit.
Contact person for inspection/audit: ____________________________________________ Telephone # ( )__________________________
7. Form of business: Individual Joint Venture Partnership Corporation Limited Liability Company Other: ____________________________
8. Does Applicant have a Liquor License(s)? Yes No Type of Liquor License(s): ___________________________________________
What name is on the Liquor License: __________________________________________________ We will require a copy of the Liquor License if we bind.
9. Type of Customers (most applicable): Families College Students Business/Professional Military Blue Collar Other:__________________
Average age of customers: ________ Percentage of customers who arrive/depart by car/truck: _____%
Do college students frequent the Applicant’s establishment?
Yes No If yes, what % do they comprise of the Applicant’s evening clientele? ______%
10. Description of Operations (check ALL operations that are applicable):
Bar/Tavern (may serve food){A} Billiard/Pool Hall {D} Bowling Alley {E}
Package Store (retail) {L,K} Convenience/Grocery Store {F,G} Night Club/Cabaret {J}
Comedy Club {P} Dance Hall/Ballroom {H} Beverage Distributor (wholesale) {C,B}
Catering/Banquets/Hall Rental;(Attach Hall Rental/Caterers Supplement) {Q} Hotel/Motel; have mini-bars in rooms? Yes No
Private Club; specify type (American Legion, VFW, Country Club, etc.): _______________________________________ {M}
Restaurant: specify type (American, Chinese, Italian, Seafood, etc.): __________________________________________ {N}
Other; describe: ______________________________________________________________ {O}
11. Does Applicant dispense or provide alcoholic beverages for off-premises events? Yes No If yes, Must complete Special Events Application.
Does Applicant have any Catering/Banquet Hall/Hall Rental Operations?
Yes No If yes, Must complete Hall Rental/Caterers Supplement.
Within the past 5 years, has the Applicant had any Assault & Battery Claims?
Yes No If yes, Must attach a separate sheet explaining each claim.
12. Amusement devices and/or sports facilities? Yes No
Devices with removable parts {balls, pucks, racquets, etc.} (provide # of all that apply):
Pool tables; #_____ Foosball; #_____ Air Hockey; #_____ Bowling Games; #_____ Shuffleboards; #_____ Dart Boards; #_____
Skee-Ball; #_____
Other; #_____; describe: _____________________________________________________________________
Totally enclosed devices (provide # of all that apply):
Video Games; # _____ Gambling Machines; #_____ Pinball Machines; #_____ Televisions; #_____ Mechanical Riding Machines; #_____
Other; #_____; describe: ___________________________________________________________________________________________________
Sports facilities (check all that apply):
Volleyball Basketball Hockey Other; describe: _______________________________________
13. Does Applicant have entertainment? Yes No If yes, check ALL that are applicable below:
Juke Box DJ; # of days per week: _____ Karaoke; # of days per week: _____ Solo musician/vocalist; # of days per week: _____
Exotic/go-go dancers/adult entertainment Stage/floor show or contests; describe: _________________________________________________
Band with 1-3 members: # of days per week: _____ Band with 4+ members; # of days per week: _____ Other; describe: ______________________
If the Applicant has bands or DJs as part of the entertainment, are pyrotechnics allowed? Yes No
Type of music:
Top 40 Country Classic Rock & Roll Soft Rock Jazz Alternative Rap R&B Disco Other: ____________
14. Is dancing allowed? Yes No If yes, # of days per week: _____ Size of dance floor: ____________________ square feet
15. Any consumption promotions such as happy hour, ladies night, etc.? Yes No If yes, give details: # of days per week: _______________________
Times & duration of promotions (i.e., 5pm to 7pm): ____________________ Describe alcohol/food discounts: ____________________________________
16. Area surrounding premises (check the most applicable): Downtown district Industrial Rural Entertainment district Suburban commercial
Urban commercial Residential Seasonal/resort: operate all year? Yes No Other; describe:__________________________________
Premises located within an incorporated municipality?
Yes No If yes, population of municipality: ________________________
Is there a college or university within a 3-mile radius of the Applicant’s premises? Yes No If yes, give name:____________________________________
FORM # LLAPP (6/05) Page 1
