Fillable Liquor Liability Application (Risk Placement Services, Inc.)

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Liquor Liability Application (Risk Placement Services, Inc.)

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IAT Group
Special Products Division PO
Box 3328
Omaha, NE 68103
1-888-389-0598
_____ Acceptance Indemnity Insurance Company
_____ Acceptance Casualty Insurance Company
_____ Occidental Fire & Casualty Insurance Company
_____ Wilshire Insurance Company
Liquor Liability Application
Please answer ALL questions in full.
Incomplete and/or missing answers will cause delays in processing or may cause coverage to be declined.
Policy Period: ______________________________________ to __________________________________________
1. Applicant Information: _____Individual _____Corporation _____Partnership _____Other: ________________
a. Name: ____________________________________________________________________________________
Mailing Address: ___________________________________________________________________________
Location Address: __________________________________________________________________________
b. Has the Applicant, any partner, or any officer of the Applicant been the subject of any voluntary or
involuntary bankruptcy proceedings within the past 5 years? _________________ YES _______________ NO
If yes, explain: ____________________________________________________________________________
c. Number of years in business: _________________________________________________________________
d. Web Site Address: _________________________________________________________________________________________
2. Name on Liquor License: _____________________________________________________________________
Note the name on the Liquor License must be the same as the Named Insured.
3. Limits Desired: $____________________________Occurrence $____________________________Aggregate
4. Type of establishment: _______ Convenient/Kwik Shop Store _______ Package/Grocery Store _______ Casino
_____ Restaurant _____ Bar/Tavern _____ Wholesaler/Distributor _____ Club (Type): __________________
_____ Catering _____ Manufacturer/Brewery _____ Banquet/Hall Facilities _____ Other: _________________
If Banquet/Hall Facilities, Catering or Club is selected, you must also complete their addendum.
5. a. Entertainment: _______ YES _______ NO If yes, how many times a week: ____________________
If Yes, describe: _______
___ Disco _________ Topless/Go Go __________ Live Band __________ Karaoke
___________ DJ ____________ Rock & Roll ____________ Juke Box ____________ # of Electronic Games
__________ # of Mechanical Devises _________ # of Pool Tables Other: ___________________________
b. Happy Hour? ______ YES ______ NO If Yes, describe: _______________________________________
How many days per week? ______ Happy Hour time: __________ A.M./P.M. to _________ A.M./P.M.
Any 2 for 1 drinks or drinks under $1.50 during happy hour or regular business hours? ______ Yes ______ No
c. Size of dance floor (square foot): _____________
d. Cover Charge: _____ YES ______ NO
6. Are any tournaments held on premises –
check as applicable: ____Pool Tables ____Shuffle Board ____Dart Boards
How Often? __________________________________ Other: _________________________________________
CQ-APP (04/05) Page 1 of 3
7. Does the insured sponsor any activities? If Yes, describe: _____________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
8. Area surrounding premises: _____ Downtown District _____ Residential _____ Shopping Center _____ Rural
_____ Commercial _____ Industrial _____ Seasonal/Resort _____ College Campus _____ Other: ____________
9. Is parking area well lighted? ______ YES ______ NO
10. Any outdoor serving areas? If Yes, describe: _______________________________________________________
11. Type of Clientele: _____ Area Residents _____ Tourists _____ College Students _____ Other: _____________
Age: _________________ % Under 25 _________________ % 25 to 30 __________________ % Over 30
12. Management:
a. Any security? ______ YES ______ NO If Yes, how many? ____________________________________
______ Bouncer ______ Doorman ______ Off Duty Police ______ Other : _________________
b. Is a gun kept on premises? ______ YES ______ NO
If Yes, is it loaded? ______ YES ______ NO Where’s the gun kept? _____________________________
c. Number of bartenders on duty? ______ Female ______ Male
d. Have all servers completed a certified training course? ______ YES ______ NO
If yes, which course ie…TABC, TIPS, RAMP? Describe: _________________________________________
e. Procedures in place for those under the influence? ______ YES ______ NO
I
f so, Describe: ___________________________________________________________________________
f. Who is checking I.D.’s? ____________________________________________________________________
g. When are I.D.’s checked? ___________________________________________________________________
13. General Information:
a. How many days a week is location open? _______________________________________________________
b. Opening and closing Hours: ______________________ A.M./P.M. to ______________________ A.M./P.M.
c. Seating Capacity: _______________________ Dining Room ___
______________________ Bar Area
d. Does establishment allow alcohol to be brought in (BYOB)? ______ YES ______ NO
14. Insurance History:
a. Previous liquor liability insurer (full name of insurance company): ___________________________________
b. Did the previous carrier write a claim’s made policy? ______ YES ______ NO
c. Describe any losses claimed or sustained within the past 5 years whether insured or not (include loss amount):
_
_________________________________________________________________________________________
__________________________________________________________________________________________
CQ-APP (04/05) Page 2 of 3
15. Has liquor liability insurance coverage been denied, cancelled or non-renewed during the last 3 years?
______ YES ______ NO If Yes, Explain: _____________________________________________________
_____________________________________________________________________________________________
16. Has the insured been fined within the last 3 years? ______ YES ______ NO
If Yes, give dates and describe violations: _________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
17. Annual Gross Receipts: Present – Estimated Prior Year: ________ Prior Year: ________
On-premises Alcohol Receipts $___________________ $___________________ $____________________
Off-premises Alcohol Receipts $___________________ $___________________ $____________________
Food Receipts $___________________ $___________________ $____________________
Total Alcohol & Food Receipts $___________________ $___________________ $____________________
18. Who to contact for an Audit and /or Inspection? Name: _______________________ Phone #: ______________
19. Name of current General Liability carrier? _________________________________________________________
General Liability policy period: ____________ to ___________ General Liability policy limits: $ __________
Is the Assault & Battery excluded on the General Liability policy? ________________ YES ______________ NO
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.
_________________________________ ________________________________
Applicants Signature Date
_________________________________ __________________ ___________
Agency Title Date
_________________________________ _________________________________
Signature/Broker Address
_________________________________
City, State & zip
CQ-APP (04/05) Page 3 of 3
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Liquor Liability Application (Risk Placement Services, Inc.)

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Completed 30 July 2020

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