Fillable BARS/RESTAURANTS/TAVERNS GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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BARS/RESTAURANTS/TAVERNS GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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GL-A PP-18s (8-18) Page 1 of 7
BARS/RESTAURANTS/TAVERNS GENERAL LIABILITY APPLICATION
Applicant’s Name:
Mailing Address:
Location Address:
Agency Name:
Agent No.:
Address:
E-mail:
Phone No.:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
Applicant is: Individual Corporation Partnership Joint Venture
Limited Liability Company Other (Specify)
Website Address:
E-ma il Address: Phone No.:
Inspection Contact:
E-ma il Address: Phone No.:
Limits of Liability and Deductible Requested:
General Aggregate (other than Products/Completed Operations)
$
Products and Completed Operations Aggregate $
Personal and Advertising Injury (any one person or organization) $
Each Occurrence $
Damage to Premises Rented to You (any one premise) $
Medical Expense (any one person) $
Other Coverages, Restrictions and/or Endorsements:
$
Deductible $
GL-A PP-18s (8-18) Page 2 of 7
1. Classification of risk (select all that apply):
Banquet facility Bring your own bottle establishment Disco Membership club
Bar/Tavern Cabaret Country club Fine Dining Nightclub
Bowling center Comedy Club Deli Gentlemen’s/Strip Club Restaurant
2. Annual gross sales:
Past Twelve (12) Months
Next Twelve (12) Months
Alcohol Sales
Food Sales
Gambling
Other
Total
3. Number of years in business: ...........................................................................................................
4. Number of years under current management: .................................................................................
5. Opening and closing time per day:
6. Schedule of Hazards:
Loc.
No.
Classification Description
Class.
Code
Exposure
Premium Basis
(s) Gross Sales
(p) Payroll
(a) Area
(c) Total Cost
(t) Other
7. Are there any catering services available? ...................................................................................... Yes No
If yes: Off premises On premises Gross sales: ...........................................................$
8. Types of meals served: Full meals Short order
9. Square footage of bar/tavern/restaurant: .........................................................................................
10. Is applicant a BBQ restaurant? ........................................................................................................ Yes No
11. Is applicant a microbrewery that sells their products for off premises consumption? .................... Yes No
12. Are facilities available for use or rent for private parties, receptions, banquets or similar affairs? Yes No
If yes: Number of times per year: ......................................................................................................
Describe:
GL-A PP-18s (8-18) Page 3 of 7
13. Are patrons allowed to drink their own alcoholic beverages on the premises? .............................. Yes No
If yes:
a. Are there procedures in place for handling violent or disruptive patrons? ......................................... Yes No
b. Is there table service? .................................................................................................................. Yes No
c. Does applicant also sell alcohol? .................................................................................................. Yes No
14. Does applicant advertise or promote “happy hour” or other events when drinks are sold at a
lower price than usual? ...................................................................................................................
Yes No
15. Does applicant subscribe to a taxi or other service providing transportation home to apparently
intoxicated persons? .......................................................................................................................
Yes No
If yes, describe:
16. Is there Hookah exposure (communal smoking)? ........................................................................... Yes No
If yes:
a. Any blending of tobacco by applicant? .......................................................................................... Yes No
If yes, what percentage of tobacco products: ................................................................................. %
b. Does applicant import any tobacco products? ................................................................................ Yes No
If yes, what percentage of tobacco products: ................................................................................. %
c. Does applicant allow underage persons to purchase and/or use the products? ................................ Yes No
d. How often does applicant clean pipes, tubing and mouthpieces?
17. Entertainment:
a. Is there any live entertainment on premises? ................................................................................. Yes No
If yes: Number of times per week: ...............................................................................................
Describe: (include go-go dancers, topless, disco, exotic, female/male):
b. Is there dancing? ......................................................................................................................... Yes No
If yes: Number of times per week: ...............................................................................................
Square footage of dance floor: ..........................................................................................
c. Does applicant have any mechanical or amusement devices? ........................................................ Yes No
If yes: How many? .....................................................................................................................
Describe:
d. Is there a minimum or cover charge? ............................................................................................ Yes No
e. Are there sports on the premises? ................................................................................................ Yes No
If yes: Provide complete details:
f. Are sports sponsored off premises ? .............................................................................................. Yes No
If yes: Number of times per week: ...............................................................................................
Give details:
g. Does applicant sponsor any special events?.................................................................................. Yes No
If yes: Describe:
GL-A PP-18s (8-18) Page 4 of 7
h. Is there any gambling? ................................................................................................................. Yes No
If yes: Are there any “live” dealers?............................................................................................. Yes No
Number of gambling machines:.........................................................................................
i. Is there a play area for children? ................................................................................................... Yes No
j. Are there any drinking games (i.e., beer pong, flip cup)? ................................................................ Yes No
If yes: Describe:
k. Are there any pub crawls (pedal bus or motorized)? ....................................................................... Yes No
l. Does applicant own or sponsor party buses? ................................................................................. Yes No
m. Are there any hatchet/axe throwing activities? ............................................................................... Yes No
18. Does applicant have parking area?.................................................................................................. Yes No
If yes, is parking area well lit? ............................................................................................................. Yes No
19. Does applicant subcontract valet parking services on restaurant premises? ................................. Yes No
If yes: Annual subcontract cost: .........................................................................................................$
Do subcontractors provide certificate of insurance with liability limits equal or greater than our
applicant? .........................................................................................................................................
Yes No
Do written contracts contain hold harmless agreements in favor of the applicant? .................................. Yes No
Does applicant require all subcontractors to include the applicant as an additional insured on the General
Liability and Garage policies? .............................................................................................................
Yes No
20. Clientele:
Local residents Families Retirement community College students Seasonal residents
Median age of patrons: 18-25 26-30 31-40 41 and over
Are premises located near a college or university?............................................................................... Yes No
21. In the past five years, has applicant been cited by the Liquor Control Commission? ..................... Yes No
If yes, give date(s) and full explanation:
22. Are police records and background checks conducted on employees? ......................................... Yes No
23. Number of bouncers, doormen or security personnel: ....................................................................
Are bouncers, doormen or security personnel employees? ................................................................... Yes No
Are bouncers, doormen or security personnel independent contractors?.................................................... Yes No
If independent contractors, do they provide Certificates of Insurance and Additional Insured Endorse-
ments to the applicant? ......................................................................................................................
Yes No
24. Does applicant have Workers’ Compensation coverage in force?................................................... Yes No
Total number of employees:................................................................................................................
25. During the past three years, has any company ever canceled, nonrenewed, declined or refused
similar insurance to the applicant? (Not applicable in Missouri) ........................................................
Yes No
If yes, explain:
26. Does risk engage in the generation of power, other than emergency back-up power, for their own
use or sale to power companies? ....................................................................................................
Yes No
If yes, describe:
27. Doe s applicant have other business ventures for which coverage is not requested? ..................... Yes No
GL-A PP-18s (8-18) Page 5 of 7
If yes, explain and advise where insured:
28. Additional Insured Information:
Name
Address
Interest
29. Prior Carrier Information:
Year:
Year:
Year:
Carrier
Policy No.
Coverage
Occurrence or Claims Made
Total Premium
30. 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.
Check if no losses in the last three years.
Date of
Loss
Description of Loss
Amount
Paid
Amount
Reserved
Claim Status
(Open or
Closed)
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. (Not applicable in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY, OH,
OK, OR, RI, TN, VA, VT or WA.)
NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or infor-
mation 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 policy holder or claimant for the purpose
of defrauding or attempting to defraud the policy holder 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.
GL-A PP-18s (8-18) Page 6 of 7
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an
insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addi-
tion, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: 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
of the third degree.
NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be pre-
sented 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, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or state-
ment 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, which
is a crime and subjects such person to criminal and civil penalties.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject
to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: 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.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud against
an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: 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.
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information
is guilty of a felony.
NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents a
materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under
state law.
FRAUD WARNING (APPLICABLE IN 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
include imprisonment, fines, and denial of insurance benefits.
NEW YORK OTHER THAN AUTOMOBILE 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 fraudu-
lent 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.
GL-A PP-18s (8-18) Page 7 of 7
APPLICANT’S STATEMENT:
I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements
are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying. (Kansas:
This does not constitute a warranty.)
APPLICANT’S NAME AND TITLE:
APPLICANT’S SIGNATURE: DATE:
PRODUCER’S SIGNATURE: DATE:
AGENT NAME: AGENT LICENSE NUMBER:
NAME AND PHONE NUMBER OF INDIVIDUAL TO CONTACT FOR INSPECTION/AUDIT:
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional information
as to the nature and scope of the report, if one is made, will be provided.
Agent Email: Preferred Method of Correspondence Email Fax Mail
Applicant Email: Preferred Method of Correspondence Email Fax Mail
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BARSRESTAURANTSTAVERNS GENERAL LIABILITY APPLICATION (Colonial General Insurance Agency, Inc)

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Completed 22 August 2020

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