Fillable KINSALE Liquor Liability Supplemental Application

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KINSALE Liquor Liability Supplemental Application

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The KINSALE Liquor Liability Supplemental Application form is 4 pages long and contains:

  • 1 signature
  • 59 check-boxes
  • 20 other fields

Country of origin: US
File type: PDF

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Page 1 of 4
LIQUOR LIABILITY SUPPLEMENTAL APPLICATION
COMPLETE IN ADDITION TO ACORD APPLICATIONS
ATTACH ADDITIONAL SHEETS AS NECESSARY
ANSWER ALL QUESTIONS. If not applicable, indicate N/A.
DATE:
APPLICANT NAME:
MAILING ADDRESS:
STREET ADDRESS (if different):
CITY, STATE, ZIP CODE:
WEBSITE: www.
1) Receipts:
Total Receipts: $ Food Receipts:$ Liquor Receipts:$
2) Type of risk:
Bar/Tavern Casino Catering Convenience/Grocery Store
Gentleman’s Club Liquor Manufacturer Night Club Restaurant
3) Is there a dance floor or an area for dancing? Yes No
4) Does the insured feature any entertainment? Yes No
If yes, how often? 1-2 times per week 3+ times per week Banquets only
Check all that apply: DJs Live bands Comedians Open mic nights Karaoke
APPLICANT’S INFORMATION
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 4
5) Are there any security guards/”bouncers” on the premises? Yes No
a. Are they armed or unarmed?
Armed: Firearms Tasers Pepper Spray Other (describe)
Unarmed:
6) Are guards employees or from a contracted guard service? Employees Guard Service
7) Are off duty police officers used? Yes No
a. Do they carry their service revolvers? Yes No
8) Does insured have a valid liquor license? Yes No
9) Number of servers?
10) Have all servers been through proper server training? Yes No
11) Are driver’s licenses or other means of identification scanned into a document or image retention Yes No
system?
12) Are security cameras in use? Yes No
a. What area is covered by cameras? Interior Exterior
13) Are employees or other persons serving alcohol permitted to consume alcohol during their Yes No
hours of employment or service?
14) Does the insured ever offering the following types of drink specials? Yes No
Happy Hour Multiple Drink Incentives BYOB
Complimentary Drinks All You Can Drink Specials Ladies Night
15) Are procedures in place regulating the sale of alcohol to minors or those under the influence? Yes No
If yes, please describe:
16) Have you ever been assessed a fine for violation of a law concerning the sale of alcohol or had your Yes No
liquor license suspended?
17) Have there been any liquor liability claims over the past 3 years? Yes No
If yes, please describe:
Page 3 of 4
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA,
NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN,
AND WYOMING APPLICANTS: In some 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, for the purpose of misleading, conceals information concerning
any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: 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 policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: 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 addition, 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 insurance company files a statement of claim
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: 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.
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 denial of insurance benefits.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
NOTICE TO NEW MEXICO 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 civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 shall also be subject to a civil penalty not to exceed $5,000 and the stated value of
the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she 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: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim for
the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an application
for insurance or statement of a 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 the person to criminal and civil penalties.
NOTICE TO TENNESSEE 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 include imprisonment, fines and denial of insurance benefits.
Page 4 of 4
NOTICE TO VIRGINIA 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 include imprisonment, fines and denial of insurance benefits.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit
any material facts. The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to
the effective date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or
withdrawn based upon such changes at our sole discretion. Completion of this form does not bind coverage. Applicant’s acceptance of the company’s
quotation is required prior to binding coverage and policy issuance. All written statements and materials furnished to the company in conjunction with this
application are hereby incorporated by reference into this application and made a part of this application.
Applicant: Title:
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
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KINSALE Liquor Liability Supplemental Application

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Completed 2 July 2020

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