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

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Liquor Liability Application (Risk Placement Services, Inc.)

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The Liquor Liability Application (Risk Placement Services, Inc.) form is 3 pages long and contains:

  • 1 signature
  • 42 check-boxes
  • 158 other fields

Country of origin: US
File type: PDF

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People’s United Insurance Agency / Liquor Liability Application Page 1 of 3
Liquor Liability Application
Must be completed in full and signed by applicant.
New Renewal of Policy Number:
Requested Effective Date:
INSURED INFORMATION If more than one location, please complete and attach supplemental application.
1. Name of applicant (show all names including legal and dba):
2. Mailing Address:
3. Location Address:
Number of Stories: Any Patrons on other floors?: Yes No
What are other floors used for?:
Second Floor Capacity: Describe 2
nd
floor exits:
4. Website address:
5. Name and phone number of contact person:
6. The applicant is: Individual Partnership Corporation Other (describe)
Does applicant have valid liquor license? Yes No License #:
Name on license:
7. Previous liquor liability carrier: Limits: Annual Premium:
8. Name of General Liability Insurance Company: Expiration Date:
Policy Limits: Occurrence: Aggregate: Does GL exclude Assault & Battery? Yes No
9. Within the past 5 years;
a. Has applicant’s liquor coverage been cancelled or non-renewed? Yes No
b. Has applicant’s liquor license ever been suspended or revoked? Yes No
c. Has applicant or any owner, officer or partner filed bankruptcy? Yes No
If yes to questions 9. a, b or c please explain:
10. Type of business (check all that apply):
Bar/Tavern Retail/Take Out/Package/Convenience Store Private/Fraternal/Country Club
Bowling Alley Gas No Gas Members only? Yes No
Billiard/Pool Hall Adult Night Club or Bar Restaurant Catering/Banquet Hall
Off-Premises Caterer Concessionaire Casino Other (describe):
PREMIUM BASIS
11. a) Gross annual receipts for consumption on premises:
Past 12 Months Next 12 Months
Food: $ $
Alcohol: $ $
Other: $ $ Describe other:
b) If applicant sells liquor for off premises consumption (over the counter), or sells liquor off premises (catering) please provide
those receipts here:
Off Premise
Food: $
Alcohol: $
Other: $
c) Desired Limits: Each Common Cause: Aggregate:
programs@peoples.com
www.peoples.com/insurance.com
People’s United Insurance Agency / Liquor Liability Application Page 2 of 3
CLAIMS/VIOLATIONS Please attach 5 years of currently valued loss information if applicable.
12. Within the last 5 years;
a. Has applicant been fined or cited by violations related to illegal activities or the sale or service of alcohol? Yes No
b. Has applicant had any reported liquor liability claims or notification of potential liquor liability claims? Yes No
c. Has the applicant had any reported claims or notification of potential claims related to Assault & Battery? Yes No
13. Is the applicant aware of any other incidents, conditions, circumstances, defects or suspected defects
which may result in claims against the applicant? Yes No
If yes to questions 12 a., b., c. or 13, please provide details, date(s) of citations, status and description of claim(s):
EMPLOYEES/MANAGEMENT & PROCEDURES
14. Are all alcohol serving employees certified in a formal alcohol training course? Yes No
If yes, provide name of course (e.g., TIPS, TAM, RAMP, BEST, etc.)
15. How long has current owner been in business at this location?
16. a. How many years has Manager worked at this establishment? b. Hours full time Manager is on duty:
If three years or less for questions 15 & 16 a, please describe prior experience in this type of business:
17. How many days per week is location open?
18. Hours of operation: Mon.-Thurs.: Fri.: Sat.: Sun.:
19. Are employees permitted to consume alcohol during their hours of employment? Yes No
20. What is the distance to the nearest college campus?
21. What is the average age of patrons? Under 21 21-25 26-30 31-40 41+
22. Does applicant offer Happy Hour or other Promotional Events? Yes No
If yes, describe type of drink, prices and time offered:
23. Does applicant offer:
Multiple drink incentives (i.e., 2 for 1, every 3
rd
drink is free, etc.)? Yes No
Complimentary drinks or “all you can drink” specials? Yes No
Are flaming or ignited drinks served? Yes No
24. What is the average cost of beer/wine/mix drinks? Beer Wine Bottle Wine Glass Mix Drinks
25. Does applicant permit “BYOB” or set-ups? Yes No If yes, explain:
26. Seating capacity in dining room: Bar area: ever been cited for over crowding? Yes No
27. Are persons under the legal drinking age allowed on premises after 10 p.m.? Yes No
28. Are bouncers or door persons employed? Yes No
29. Are Security Guards employed? Yes No
If yes, are they: Armed? Yes No Off Duty Police? Yes No
30. Are background checks done on the security staff? Yes No
31. Is there an establishment procedure for handling violent or disruptive patrons? Yes No
32. Are any actions taken to prevent obviously intoxicated persons from driving? Yes No
33. Do you provide 3
rd
party transportation i.e. cabs? Yes No
If yes, please explain:
34. What steps are taken to avoid selling or serving alcohol to persons under age?
People’s United Insurance Agency / Liquor Liability Application Page 3 of 3
TYPE OF RISK & ENTERTAINMENT
35. Does applicant feature any entertainment or other promotional events? Yes No If yes, how often?
Is there a cover charge? Yes No If yes, how much?
Entertainment is:
DJ Karaoke Solo Vocalist Foam Party Band Pyrotechnic Comedy Club
Stage/Floor show, contests or other promotional events (describe):
Describe type of music:
Top 40s/pop Classic Rock Soft Rock Alternative Country
Jazz R&B RAP Other:
36. a. Is there a dance floor? Yes No If yes, square footage:
b. Any raised or elevated dancing areas? Yes No If yes, describe:
37. Are there amusement devices on premises? Yes No If yes, describe:
38. a. Are facilities available for banquets, receptions, weddings, private affairs, etc.? Yes No
If yes, how many functions are handled annually? Describe types:
b. Describe who is dispensing the alcohol:
FRAUD STATEMENT: A 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.
WARRANTIES: I/we warrant the information contained herein is true and that it shall be the basis of the policy of insurance and deemed incorporated
therein, should the Company evidence its acceptance of this application by issuance of a policy. I/we agree that such policy shall be null and void if such
information is false or misleading in any way as this would materially affect acceptance of a risk by the Company. I/we hereby authorize release of claim
information from any insurers or their general agent. I/we warrant that premises liability coverage will be maintained at limits at least equal to the liquor
liability limits during the entire term of the liquor policy. I/we agree to submit records for audit by the Company upon termination or expiration of this policy
for the determination of actual gross receipts during the period of coverage, it requested.
Signature of
Applicant** Title Date
(Must be owner, officer or partner) (Required) (Required)
Signature of Producing Agent** Date
*Signing this application does not require the insurer to issue a policy of insurance or require the applicant to accept the insurance offered.
** The undersigned hereby warrants and certifies that all information contained herein is correct; That this form was completed and then signed by the
insured/applicant; That a completed copy hereof has been given to the insured/applicant; and that I am retaining a duplicate signed copy hereof.
Producing Agency:
Contact Person:
Address:
Tel: Fax:
Email:
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Liquor Liability Application (Risk Placement Services, Inc.)

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Completed 23 November 2020

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