Fillable COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

Fill Online, Printable, Fillable, Blank COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers) Form

Use Fill to complete blank online STRICKLAND INSURANCE BROKERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

On average this form takes 9 minutes to complete

The COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers) form is 2 pages long and contains:

  • 2 signatures
  • 26 check-boxes
  • 16 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Strickland Insurance Brokers forms online.

BROWSE STRICKLAND INSURANCE BROKERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
C‐APP026‐0815 Page1of2
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION - LIQUOR LIABILITY - SUPPLEMENTAL APPLICATION
ACORD Application also required - Check all applicable checkboxes below
General Agent: Date:
Insured:
Insured Mailing Address:
Insured’s Web Address:
Insured Contact Name: Phone Number:
PROHIBITED (check all that apply to your operations)
Athletic games, Contact sports, Contests of any kind
Bouncers or employees with any type of security related duty
BYOB establishments
Casinos, Gentlemen’s Clubs, stand-alone bar/tavern risks
Catering operations that are 100% liquor, no food
Firearms on premises, but off-duty peace officers are acceptable
Guides and outfitters, Hunt Clubs
Hours extend beyond 2 a.m.
License revocations
Mechanical rides or devices
Mobile Home Parks
Procedures not formally in place to restrict the sale of alcohol to minors or those under the influence
Stand alone coverage without the support of the CGL
State(s) the insured operates in include HI, IA, MI, MN or NM
YEARS IN BUSINESS / EXPERIENCE
_____ Years in business as the ‘Named Insured’ indicated on this application
_____ Years’ experience in the operations indicated on this application - Attach resumes if available
Has applicant had an insurance policy cancelled or non-renewed in past 3 years? If yes, explain.
(Missouri Applicants - Do not answer this question)
Applicant in receivership
Bankruptcy (Chapter 7, 11 or 13) has been filed in past 5 years
LICENSING
Licenses and permits as required by law are in place
TIPS / TOPS LIQUOR SERVICE TRAINING
Training (TIPS, TOPS or similar) is provided to ALL employees handling liquor
C‐APP026‐0815 Page2of2
LIQUOR LIABILITY - SUPPLEMENTAL APPLICATION
LOSS HISTORY / CITATIONS
Three years of loss history information provided on ACORD application or attached to this application
Assault and Battery incident(s) have occurred in the past 3 years
Citations, fines or suspensions have been received in the past. If yes, explain:
OPERATIONS / EXPOSURES / CONTROLS
Live entertainment
College or university nearby and location has the reputation as being a school hangout for students
Cover charges are collected
ID’s are consistently checked
RECEIPTS
Total of Liquor Receipts Only
$
GENERAL FRAUD STATEMENT (Not applicable in all states.)
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, may be committing a fraudulent insurance act, and may be subject to
a civil penalty or fine.
The undersigned is an authorized representative of the applicant and certifies that reasonable inquiry has been made to
questions on this application. He/She certifies:
The answers are true, correct and complete to the best of his/her knowledge.
They agree to the Privacy and Fraud provisions found in the ACORD-125 (Commercial Insurance Application)
and understand those provisions also apply to this supplemental application.
SIGN AND DATE
PRODUCER’S SIGNATURE DATE
APPLICANT’S PRINTED NAME DATE
APPLICANT’S SIGNATURE DATE
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 17 July 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document