Fillable LIQUOR LIABILITY APPLICATION (Special Risks)

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LIQUOR LIABILITY APPLICATION (Special Risks)

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LLAPP 02/18
LIQUOR LIABILITY APPLICATION
SECTION I.
1350 E. Touhy Ave, Suite 200W
Toll Free
Fax
comnewbusiness@foundersinsurance.com
(800) 972-8778
(847) 795-0061
Des Plaines, IL 60018-3303
1. Effecve Date: to
2. Applicant’s Name:
3. Applicant’s Mailing Address:
4. City: State: Zip Code:
5. Email Address of Primary Contact: Phone:
6. Inspecon Contact Name: Phone:
7. Number of Locaons to be Insured (complete one applicaon per locaon):
8. Locaon Address:
9. City: State: Zip Code:
10. Type of Business (check all that apply):
Bar/Tavern Nightclub/Dance Bar/Discotheque Adult Entertainment Club
Restaurant (1-25% liquor sales) Restaurant (26-49% liquor sales) Banquet Halls/Caterer
Fraternal/Private/Social clubs Liquor/Convenience/Grocery store Wholesale Distributor
Comedy Club Pool/Billiard Hall; Bowling Alley; Other
Sports Venue
11. What year did the applicant start business at this locaon?
12. How many years’ experience does applicant have owning or managing this type of operaon?
13. Esmated Receipts:
Annual Food Receipts On-Premises $
Annual Food Receipts Off-Premises $
Annual Food Receipts On-Premises Banquet/Rental Hall $
Annual Liquor Receipts On-Premises (including beer & wine) $
Annual Liquor Receipts Off-Premises Package Sales (including beer & wine) $
Annual Liquor Receipts On-Premises Banquet/Rental Hall (including beer & wine) $
Annual Liquor Receipts Off-Premises Catering (including beer & wine) $
Annual Liquor Receipts Off-Premises Distribuon Sales (including beer & wine) $
Page 1
LLAPP 02/18
14. and 15.
Queson 14 - Coverage Limits and Queson 15 - Assault & Baery Buy-Back Limits
Page 2
Alabama Only - All Classes EXCEPT stores and wholesale distributors (Assault & Baery Buy-Back limits
not available):
Liquor Limits:
$100,000/$200,000
All States except AL, CO, MI, MN & IA. In Illinois Assault & Baery coverage is included:
Liquor Limits:
Assault & Baery
Buy-Back Limits:
$100,000/$200,000 $300,000/$600,000 $500,000/$1,000,000
$1,000,000/$1,000,000 $1,000,000/$2,000,000
$50,000/$50,000 $100,000/$100,000 $300,000/$300,000
$500,000/$500,000 $1,000,000/$1,000,000
Colorado Only (No Assault & Baery Buy-Back limits available for coverage limits $25,000/$50,000):
Liquor Limits:
Assault & Baery
Buy-Back Limits:
$25,000/$50,000 $100,000/$200,000 $300,000/$600,000
$500,000/$1,000,000 $1,000,000/$1,000,000 $1,000,000/$2,000,000
$50,000/$50,000 $100,000/$100,000 $300,000/$300,000
$500,000/$500,000 $1,000,000/$1,000,000
Michigan Only (No Assault & Baery Buy-Back must be included at minimum limit of $50,000/$50,000):
Liquor Limits:
Assault & Baery
Buy-Back Limits:
$50,000/$100,000 $100,000/$200,000 $300,000/$600,000
$500,000/$1,000,000 $1,000,000/$1,000,000 $1,000,000/$2,000,000
$50,000/$50,000 $100,000/$100,000 $300,000/$300,000
$500,000/$500,000 $1,000,000/$1,000,000
Minnesota Only (Assault & Baery is included at occurrence limits):
Liquor Limits:
$300,000/$310,000 $300,000/$600,000 $500,000/$1,000,000
$1,000,000/$1,000,000 $1,000,000/$2,000,000
Iowa Only (Assault & Baery coverage is included):
Combined Single Limits:
Split Limits:
$150,000/$300,000 $200,000/$400,000 $300,000/$600,000 $400,000/$800,000
$500,000/$1,000,000 $750,000/$1,500,000 $1,000,000/$2,000,000
$50,000/$100,000/$200,000 (PD=$5,000) $50,000/$100,000/$200,000 (PD=$50,000) $75,000/$150,000/$300,000
$100,000/$200,000/$400,000 $125,000/250,000/$500,000 $250,000/$500,000/$1,000,000
LLAPP 02/18
16. Assault & Baery Buy-Back limit provided under General Liability Coverage? Yes No
Assault & Baery Buy-Back limit provided under General Liability Coverage $
17. List all claims & suits related to liquor liability including claims related to assault & baery brought against
applicant within past (5) years. (5 years loss runs preferred, minimum 3 years currently valued loss runs
required to bind)
18. What is the latest hour of Operaon? am pm 24 hours
19. Number of days applicant is open for business per week:
20. Maximum legal capacity of the premises:
21. Does the applicant feature entertainment? Yes No
If yes, check all of the following types that apply & number of mes entertainment provided:
22. Sports venue? Yes No
Type of athlec event:
Number of mes per week: per month: per year:
23. Number of pool tables: Number of bowling lanes:
24. Dancing permied? Yes No
If yes, provide dance floor area: square feet
25. Are there comedy, dinner theater, or other interacve/spectator acts? Yes No
26. Are there beer and wine sales only? Yes No
27. Are all alcohol-serving employees cerfied in a Formal Alcohol Training Course? Yes No
28. Are employees permied to consume alcohol during their working hours/aer their Yes No
shi/aer closing me?
29. Are non-employees permied to serve alcohol? Yes No
Page 3
Date of Loss Type of Loss Descripon of Loss Amount Paid Amount Reserved
Status of Claim
(O=open, C=closed)
Entertainment Type
Number of mes Number of mes Number of mes
per Week per Month per Year
DJ
Bands
Adult entertainment with exoc dancing
Karaoke
Solo Vocalist/Piano Player/Guitarist
Stage/Floor shows
Outdoor concerts
Other live performers
LLAPP 02/18
30. Is BYOB (Bring your own bole) permied at any me including banquet operaons? Yes No
a. Are patrons allowed to self-serve/pour/mix alcoholic drinks? Yes No
b. Where is BYOB alcohol kept on premises?
c. Who pours/serves/mixes alcoholic drinks?
31. Within past 3 years, has applicant’s liquor coverage been cancelled or non-renewed? Yes No
If yes, explain:
Page 4
SECTION II.
32. Does applicant have a valid liquor license? Yes No
If yes, Liquor License No.:
If no, reason for not having a valid liquor license:
Liquor License Status:
Michigan Business ID#:
33. Has license been suspended or revoked in the past 3 years? Yes No
34. Has applicant had any fines and/or citaon for violaon of laws or ordinances related Yes No
to illegal acvies or the sales of alcohol at this locaon within the past 3 years?
35. Are facilies available for banquets, recepons or private affairs? Yes No
If yes, how many funcons are handled annually?
Describe type:
Are only the applicant and its authorized employees or members permied to serve Yes No
alcohol at all events where alcohol is present?
36. Offer bole service or set-ups? Yes No
Are patrons allowed to self-serve/pour/mix alcoholic drinks? Yes No
Who pours/serves/mixes alcoholic drinks?
Is wine only offered? Yes No
Minimum number of patrons required in a group to have bole service:
37. Does or will applicant ever offer:
Drink specials/happy hours past 11pm? Yes No
Beer pong or other drinking games? Yes No
Complimentary drinks? Yes No
If yes, please provide details:
All you can drink specials or other offers involving unlimited alcoholic beverages? Yes No
38. Is beer offered for less than $1.00, including during happy hours and specials? Yes No
Fine/Citaon License Revoked
Descripon of Citaon
Acon taken to prevent
Date or suspended? future occurrences
Yes No
Yes No
Yes No
LLAPP 02/18
39. Is wine or liquor offered for less than $1.50, including during happy hours and specials? Yes No
40. What is the average age of patrons?
41. Are patrons under legal drinking age permied on premises? Yes No
42. Are patrons under the age of 21 allowed on premises aer 10pm? Yes No
43. Is this a fraternal club or social organizaon for members only? Yes No
44. Is there same day membership available? Yes No
45. Are members designated to serve alcohol, permied to consume? Yes No
46. Is self-service of alcohol by members permied? Yes No
47. Are there drive-through facilies? Yes No
If yes, do drive through facilies sell open containers or mixed drinks? Yes No
48. Are guns/weapons kept or permied on premises? Yes No
If yes, where are they kept?
49. Does Applicant employ bouncers or other security personnel? Yes No
If yes, answer quesons below:
Do they carry weapons? Yes No
Are they: Employee Independent contractors Both
Does the applicant have a wrien agreement with these contractors? Yes No
Are they required to provide a cerficate of insurance evidencing General Liability and Yes No
Assault & Baery coverage with limits equal to or greater than our policy?
50. Number of mes law enforcement have been called to establishment in last 3 years:
If response is greater than “0”, provide details:
Page 5
SECTION III.
32. Addional Insureds:
52. Expiring Liquor Liability Carrier:
Effecve Date: Expiraon Date:
Expiring Premium: $
Expiring Policy Limits: $
Deducble: $
Name Relaonship/Interest Address City, State, Zip AI/CH
LLAPP 02/18 Page 6
FRAUD WARNINGS
FOR APPLICANTS IN THE FOLLOWING STATES:
COLORADO – It is unlawful to knowingly provide false, incomplete, or misleading facts or informaon to an insurance company for
the purpose of defrauding or aempng to defraud the company. Penales 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 informaon to a policyholder or clamant for the purpose of defrauding or aempng to defraud the policyholder
or claimant with regard to a selement or award payable from insurance proceeds shall be reported to the Colorado Division of
Insurance within the Department of Regulatory Agencies.
DISTRICT OF COLUMBIA – WARNING: It is a crime to provide false or misleading informaon to an insurer for the purpose of
defrauding the insurer or any other person. Penales include imprisonment and/or fines. In addion, an insurer may deny insurance
benefits if false informaon materially related to a claim was provided by the applicant.
FLORIDA – Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an
applicaon containing any false, incomplete, or misleading informaon is guilty of a felony of the third degree.
KANSAS – Any person who commits a fraudulent insurance act is guilty of a crime and may be subject to restuon, fines and
confinement in prison. A fraudulent insurance act means an act commied by 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 or insurance agent or broker, any wrien electronic, electronic impulse, facsimile, magnec, oral, or telephonic
communicaon or statement as part of, or in support of, an applicaon for insurance, or the rang of an insurance policy, or a claim
for payment or other benefit under an insurance policy, which such person knows to contain materially false informaon
concerning any material fact thereto; or conceals, for the purpose of misleading, informaon concerning any fact material thereto.
MARYLAND – 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 informaon in an applicaon for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
NEW YORK – Any person who knowingly and with intent to defraud any insurance company or other person files an applicaon
for insurance or statement of claim containing any materially false informaon, or conceals for the purpose of misleading,
informaon 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 five thousand dollars and the stated value of the claim for each such violaon.
OHIO – Any person who, with intent to defraud or knowing that he/she is facilitang a fraud against an insurer, submits an
applicaon or files a claim containing a false or decepve statement is guilty of insurance fraud.
OKLAHOMA – 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 informaon is guilty of a felony.
OREGON – Any person who knowingly and with intent to defraud any insurance company or other person: (1) files an applicaon
for insurance or statement of claim containing any materially false informaon; or (2) conceals for the purpose of misleading,
informaon, informaon concerning any material fact, may have commied a fraudulent insurance act, which may be a crime and
may subject the person to penales.
PUERTO RICO – Any person who knowingly and with intent to defraud, presents false informaon in an insurance request form, or
who presents, helps or has presented a fraudulent claim for the payment of a loss or other benefit, or presents more than one claim
for the same damage or loss, will incur a felony, and upon convicon will be penalized for each violaon with a fine of no less than
five thousand dollars ($5,000) nor more than ten thousand dollars ($10,000); or imprisonment for a fixed term of three (3) years or
both penales. If aggravated circumstances prevail, the fixed established imprisonment may be increased to a maximum of five (5)
years; if aenuang circumstances prevail, it may be reduced to a minimum of two (2) years.
FOR APPLICANTS IN ALABAMA, ARKANSAS, ARIZONA, LOUISIANA, NEW MEXICO AND WEST VIRGINIA:
Any person who knowingly presents a false claim or fraudulent claim for payment of a loss or benefit or who knowingly presents
false informaon in an applicaon for insurance is guilty of a crime and may be subject to fines or confinement in prison.
FOR APPLICANTS IN MAINE, TENNESSEE, VIRIGINA AND WASHINGTON:
It is a crime to knowingly provide false, incomplete or misleading informaon to an insurance company for the purpose of
defrauding the company. Penales may include imprisonment, fines or denial of insurance benefits.
FOR APPLICANTS IN ALL OTHER STATES:
Any person who knowingly and with intent to defraud any insurance company or other person file an applicaon for insurance
containing any materially false informaon or conceals, for the purposes of misleading, informaon concerning any fact material
thereto commits a fraudulent insurance act, which is a crime and subjects that person to criminal and civil penales.
LLAPP 02/18 Page 7
WARRANTIES & REPRESENTATIONS
In subming this Applicaon, the undersigned warrants and represents that:
a) The informaon in this Applicaon and all aachments are true and complete as of the date submied;
b) Founders Insurance Company may, and is intended to rely upon such informaon in determining
whether to issue insurance coverage and, if so, what premium and upon what terms;
c) Upon any change in circumstances which bear upon the accuracy or completeness of the undersigned's
representaons herein, he/she shall nofy Founders Insurance Company immediately in wring and
such noce shall become a part of this Applicaon;
d) Founders Insurance Company may change the quoted premium and/or the terms of any coverage if,
subsequent to the submission of this Applicaon, it becomes aware of any such circumstances,
whether by noce from the undersigned or otherwise;
e) Neither the insured nor any principal with a control interest in the insured, has filed for bankruptcy
within 12 months prior to the date the applicaon is signed;
f) General Liability insurance is carried by the insured at limits equal to or greater then Liquor Liability on
our policy;
g) The insured has and will maintain a valid liquor license prior to the insured selling, serving or
distribung alcohol.
h) The undersigned authorizes all former liability insurers and all accounng firms to disclose to Founders
Insurance Company and/or its agents all available informaon concerning the undersigned's prior
underwring or claims history and liquor purchases and receipts, and releases all such former liability
insurers and accounng firms, Founders Insurance Company and its agents from any liability resulng
from such disclosures and use, even if such informaon is incomplete or erroneous;
i) Upon submission of this applicaon and at any me thereaer the undersigned shall make available to
Founders Insurance Company and its agents access to the premises and operaons to be insured for an
inspecon and copies of the last four (4) calendar quarters of sales tax returns;
j) The submission of this Applicaon shall not bind Founders Insurance Company or its agents to the
issuance of Insurance coverage, nor shall it bind the undersigned to accept insurance coverage; and
k) Should Founders Insurance Company issue insurance coverage which is accepted by the undersigned:
1) The undersigned shall allow Founders Insurance Company to audit its books, records, and
operaons, including an audit of the esmated liquor receipts to ensure their accuracy
and/or actual liquor receipts for any relevant me period;
2) The undersigned shall maintain accurate books and records of its liquor receipts for three (3)
years following policy expiraon and shall send to Founders Insurance Company copies of
any documents requested;
3) The premium payable for the insurance coverage is a deposit premium only and may be
adjusted by Founders Insurance Company at any me during the policy period and up to
three years aer its expiraon based upon the rates in effect at policy incepon; and
4) The undersigned shall pay any addional premium due to Founders Insurance Company
within fieen (15) days of receipt of an invoice.
Applicant’s Signature: Title: Date:
(Required) (Required) (Required)
Agent’s Signature: Date:
(Required) (Required)
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LIQUOR LIABILITY APPLICATION (Special Risks)

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Completed 9 July 2021

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