Fillable QUESTIONNAIRE LIQUOR LIABILITY Please Answer All Questions Fully. (Risk Placement Services, Inc.)

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QUESTIONNAIRE LIQUOR LIABILITY Please Answer All Questions Fully. (Risk Placement Services, Inc.)

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CGE 115 (1-10) Copyright 2009, Capitol Transamerica Corporation
Page 1 of 5
QUESTIONNAIRE – LIQUOR LIABILITY
Please answer all questions fully. Submit this Questionnaire with a completed ACORD Commercial Insurance Applicant
Information Section and prior carrier loss runs.
Name of Applicant:
Applicant mailing and lo
cation address:
Website
address:
Does ap
plicant have a valid liquor license?
Yes No
Indicate name on liquor license:
License #
Previous liquor liability carrier:
Limits:
Within the last 5 years, has applicant’s liquor
coverage been cancelled or non-renewed?
Yes No
Desired Limits: Each Common Cause: $
; Aggregate: $
Years current owne
r has been in business at this location: ________
If less than 3 years please describe prior experience:
Hours of O
peration:
to
If a Fraternal Club, are you open to the p
ublic?
Yes No
Square foot area the business occupies:
BUSINESS DESCRIPTION
Type of Business:
Standard Restaurant Fine Dining Bar or Tavern Gentlemen’s Club
Wine Bar Package Store Special Event Manufacturer
Convenience Store Fraternal Club Private Club Distributor
Off-Premises Caterer Hall for Rent Country Club Nightclub
Other:
INSURED INFORM
ATION
CGE 115 (1-10) Copyright 2009, Capitol Transamerica Corporation
Page 2 of 5
REVENUES
Total Gross Annual Receipts: Prior 12 Months Current 12 Months
Food: $ $
Alcohol (Consumption ON premises): $ $
Alcohol (Consumption OFF premises): $ $
Other: $ $
Please describe ‘Other:”
(If applicant has more than one operation at the same location, please provide breakdown of receipts by operation in
the Notes section.)
PREVENTATIVE
What procedures do you have in place to prevent the sale of alcohol to minors or those under the influence?
What step
s are taken to prevent visibly intoxicated persons from driving?
Do you have acce
ss to 3
rd
party transportation i.e. cabs? Yes No
Are all ID’s checked?
Yes No
Have all servers been certified in a formal alcohol training course?
Yes No
Number of police calls within the last year:
Types of calls:
Are employees allowed to consume alcohol during hours of employment?
Yes No
What is the average age of wait staff/servers?
Number of Fu
ll Time employees:
Part Time:
Average Num
ber of employees during peak hours of operations?
Please de
scribe training practices?
Are bouncers or doo
rpersons employed?
Yes No
Are bouncers self-employed?
Yes No
If yes, do they have general liability coverage including assault & battery?
Yes No
Do they require certificates of insurance?
Yes No
Doe they require to be added as an additional insured?
Yes No
Are Security Guards employed?
Yes No if yes, are they armed? Yes No
Are background checks done on security staff?
Yes No
EMPLOYEES/MANAGEMENT
CGE 115 (1-10) Copyright 2009, Capitol Transamerica Corporation
Page 3 of 5
What is the av
erage age of patrons?
Under 21 21-25 26-30
31-40 40+
If a bar or tavern, are persons under the legal drinking age permitted on premises? Yes No
What is the distance to the nearest college campus?
Does
the applicant offer:
Daily Happy Hour?
Yes No
Promotional Events?
Yes No
Multiple drink incentives (i.e. 2 for 1’s, 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
Drinking Contests?
Yes No
Whole liquor bottle service or setups?
Yes No
Are customers allowed to bring their own bottle or setups?
Yes No
Single drink servings larger than 24 ounces?
Yes No
Liquor or wine for less than $1.50?
Yes No
Beer for less than $1.00
Yes No
What is Building’s legal capacity as established by fire marshal/department?
What is the av
erage number of patrons during peak hours?
Does
the applicant feature any entertainment?
Yes No
If yes, describe all:
Juke Box, Karaoke Solo Vocalist Comedy Club
DJ Band – 3 members Band – 4+ members
Exotic Dancers/Adult
Entertainment
Stage/Floor Show
(describe below)
PROCEDURES
ENTERTAINMENT
CGE 115 (1-10) Copyright 2009, Capitol Transamerica Corporation
Page 4 of 5
How often?
Other Enterta
inment or Additional Descriptions:
Describe type of music:
Top 40’s/Pop Classic Rock Soft Rock
Alternative Country Jazz
R & B Other: ______
What is the si
ze of area used for dancing when tables are “shoved aside”?
Are dancin
g areas raised or elevated?
Yes No
Does the applicant charge a cover charge?
Yes No
SPECIAL EVENTS
Does your special event have a liquor license? Yes No
If “No” to the above, does the event have a subcontracted liquor vendor with license?
Yes No
Is liquor served in a fenced off area (permanent or temporary)?
Yes No
Is there a procedure for checking ID’s of patrons entering the liquor-serving area?
Yes No
Is there a limit to the number of alcoholic beverages served to a patron at any one time?
Yes No
What is that drink limit?
LOSS HIST
ORY
Violations: Within the last 5 years, has applicant been fined or cited for violations related to illegal activities or
the sale or service of alcohol?
Claims: Within the last 5 years, has applicant had any reported liquor liability claims or notifications or potential
liquor liability claims?
Yes No
If so, please explain:
Within the last 5 years, has the applicant had an
y Assault or Battery claims?
Yes No
CGE 115 (1-10) Copyright 2009, Capitol Transamerica Corporation
Page 5 of 5
Are you aware of any other incidents, conditions, circumstances, defects or suspected defects which may result
in claims against you?
Yes No
IMPORTANT NOTICE
I DECLAR
E THAT THE STATEMENTS MADE IN THIS APPLICATION ARE COMPLETE AND TRUE.
Any person who knowingly and with intent to defraud any insurance company or another person submits an
application for insurance or statement of claim containing any materially false information, or conceals for the
purpose of misleading, information containing any material fact thereto, commits a fraudulent act that is subject
to criminal and substantial civil penalties. I agree that any intentional concealment or misrepresentation of a
material fact concerning this insurance or the subject thereof may void any policy issued.
(As part of our underwriting procedures, a routine inquiry may be made to obtain applicable information
concerning character, general reputation, and credit history. Upon your written request, additional information
as to the nature and scope of the report, if one is made, will be provided.)
Applicant Signature Title Date
Producer Signature Date
Producer Name and Address
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Completed 30 July 2020

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