Fillable Application - Golf Liquor Liability Supplemental36-8523 - Golf - Liquor Liability Supplemental Application -FINAL FR…

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Application - Golf Liquor Liability Supplemental36-8523 - Golf - Liquor Liability Supplemental Application -FINAL FR…

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1. Named Insured:
2. Liquor License Name:
3. Liquor License Number:
Class of License:
4. Have you ever been assessed a fine for violation
of a law concerning the sale of alcohol, or
have you had your liquor license revoked or suspended?
Yes No
If yes, explain:
5. Have you had any occurrences that have arisen out of
the sale of any alcoholic beverage?
Yes No
If yes, explain:
6. Has your liquor liability insurance been canceled or non-renewed in the last 3 years?
Yes No If yes, explain:
7. Are servers, bartenders
and parking valets required to participate in alcohol awareness
programs? Yes No
8.
Hours of operation for the bar: M-TH
Fri Sat Sun
9. Estimated annual
receipts of liquor, wi
ne and beer: $
10. Approximate # of banquets, parties, special events
a year:
11. Estimated annual receipts of food and beverages (including Liquor): $
12. Is there a designated driver program or escort service provided for
those unable to drive?
Yes No
13. Do
you have a
beverage cart(s)? Yes No
If yes, do you provide:
Beer Yes No Wine Yes No Liquor Yes No
Is there a limit placed on the quantity of alcoholic
beverages purchased at one time?
Yes No Please explain:
14. Prior carrie
r:
GOLF - LIQUOR LIABILITY
SUPPLEMENTAL APPLICATION
Golf - Liquor Liability
Supplemental Application
Page 1 of 2
© 2014 Philadelphia Consolidated Holding Corp.
02/2014
Print Application
Clear Application
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION
FOR INSURANCE 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 THAT PERSON TO CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A
FRAUDULENT INSURANCE ACT WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL
PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS ($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION).
(NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE
INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN
PRISON.
APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION
TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY
INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN
INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A
POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT
WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO
DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY
INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS
GUILTY OF A FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED OR
PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR ANY
AGENT THEREOF, ANY WRITTEN STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE
RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT
PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN
MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING,
INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA 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 MAY INCLUDE
IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her
knowledge and belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments
submitted with this Application) are true and complete and may be relied upon by Company * in quoting and issuing the
policy. If any of the information in this Application changes prior to the effective date of the policy, the Applicant will notify
the Company of such changes and the Company may modify or withdraw the quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR
EXECUTIVE DIRECTOR)
____________________________________________________
SIGNATURE DATE
Produced By: (Section to be completed by Producer/Broker)
PRODUCER AGENCY
PRODUCER LICENSE NUMBER AGENCY TAXPAYER ID OR SS NUMBER
ADDRESS (STREET, CITY, STATE, ZIP)
Golf - Liquor Liability
Supplemental Application
Page 2 of 2
© 2014 Philadelphia Consolidated Holding Corp.
02/2014
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Application - Golf Liquor Liability Supplemental36-8523 - Golf - Liquor Liability Supplemental Application -FINAL FR

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Completed 2 July 2020

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