Form # Llapp - Application For Liquor Liability Insurance
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1
2APPLICATION FOR LIQUOR LIABILITY INSURANCE
Centrex Liquor Liability Program
Surplus Lines Producer: _________________________________________
1.
Type of Application:
New
Renewal
City/State: _________________________________________
Expiring Policy #: __________________________
Contact: _________________________________________
2.
Desired Policy Period
From: _________________________
To: _____________________________
3.
Limit Requested:
$50,000
$100,000
$200,000
$300,000
$500,000
$1,000,000
Other: $_____________
4.
Name of Applicant (show all names including legal and dba’s): ______________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
Applicant’s Mailing Address (city, state and zip):
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
Telephone #: (
) ______________________
Applicant’s total years of experience in this business: ___________
5.
Name of Location to be Insured:
__________________________________________________________________________________________
__________________________________________________________________________________________
Location Street Address (city, state and zip):
__________________________________________________________________________________________
__________________________________________________________________________________________
# of Locations to be Insured: ________ Telephone #: (
) ______________________
Applicant’s years in business at this Location: _______
NOTE: Only 1 location per application except for retail store classes (attach Multi-Location Supplement).For Special Events, use Centrex Special Event Application.
6.
If a Liquor Liability policy is issued, it will cover only the designated Insured Location(s) which will be subject to inspection and audit.
Contact person for inspection/audit: ____________________________________________
Telephone # (
)__________________________
7.
Form of business:
Individual
Joint Venture
Partnership
Corporation
Limited Liability Company
Other: ____________________________
8.
Does Applicant have a Liquor License(s)?
Yes
No
Type of Liquor License(s): ___________________________________________
What name is on the Liquor License: __________________________________________________
We will require a copy of the Liquor License if we bind.
9.
Type of Customers (most applicable):
Families
College Students
Business/Professional
Military
Blue Collar
Other:__________________
Average age of customers: ________
Percentage of customers who arrive/depart by car/truck: _____%
Do college students frequent the Applicant’s establishment?
Yes
No If yes, what % do they comprise of the Applicant’s evening clientele? ______%
10. Description of Operations (check ALL operations that are applicable):
Bar/Tavern (may serve food){A}
Billiard/Pool Hall {D}
Bowling Alley {E}
Package Store (retail) {L,K}
Convenience/Grocery Store {F,G}
Night Club/Cabaret {J}
Comedy Club {P}
Dance Hall/Ballroom {H}
Beverage Distributor (wholesale) {C,B}
Catering/Banquets/Hall Rental;(Attach Hall Rental/Caterers Supplement) {Q}
Hotel/Motel; have mini-bars in rooms?
Yes
No
Private Club; specify type (American Legion, VFW, Country Club, etc.): _______________________________________ {M}
Restaurant: specify type (American, Chinese, Italian, Seafood, etc.): __________________________________________ {N}
Other; describe: ______________________________________________________________ {O}
11. Does Applicant dispense or provide alcoholic beverages for off-premises events?
Yes
No
If yes, Must complete Special Events Application.
Does Applicant have any Catering/Banquet Hall/Hall Rental Operations?
Yes
No
If yes, Must complete Hall Rental/Caterers Supplement.
Within the past 5 years, has the Applicant had any Assault & Battery Claims?
Yes
No
If yes, Must attach a separate sheet explaining each claim.
12. Amusement devices and/or sports facilities?
Yes
No
Devices with removable parts {balls, pucks, racquets, etc.} (provide # of all that apply):
Pool tables; #_____
Foosball; #_____
Air Hockey; #_____
Bowling Games; #_____
Shuffleboards; #_____
Dart Boards; #_____
Skee-Ball; #_____
Other; #_____; describe: _____________________________________________________________________
Totally enclosed devices (provide # of all that apply):
Video Games; # _____
Gambling Machines; #_____
Pinball Machines; #_____
Televisions; #_____
Mechanical Riding Machines; #_____
Other; #_____; describe: ___________________________________________________________________________________________________
Sports facilities (check all that apply):
Volleyball
Basketball
Hockey
Other; describe: _______________________________________
13. Does Applicant have entertainment?
Yes
No If yes, check ALL that are applicable below:
Juke Box
DJ; # of days per week: _____
Karaoke; # of days per week: _____
Solo musician/vocalist; # of days per week: _____
Exotic/go-go dancers/adult entertainment
Stage/floor show or contests; describe: _________________________________________________
Band with 1-3 members: # of days per week: _____
Band with 4+ members; # of days per week: _____
Other; describe: ______________________
If the Applicant has bands or DJs as part of the entertainment, are pyrotechnics allowed?
Yes
No
Type of music:
Top 40
Country
Classic Rock & Roll
Soft Rock
Jazz
Alternative
Rap
R&B
Disco
Other: ____________
14. Is dancing allowed?
Yes
No If yes, # of days per week: _____ Size of dance floor: ____________________ square feet
15. Any consumption promotions such as happy hour, ladies night, etc.?
Yes
No
If yes, give details: # of days per week: _______________________
Times & duration of promotions (i.e., 5pm to 7pm): ____________________
Describe alcohol/food discounts: ____________________________________
16. Area surrounding premises (check the most applicable):
Downtown district
Industrial
Rural
Entertainment district
Suburban commercial
Urban commercial
Residential
Seasonal/resort: operate all year?
Yes
No
Other; describe:__________________________________
Premises located within an incorporated municipality?
Yes
No If yes, population of municipality: ________________________
Is there a college or university within a 3-mile radius of the Applicant’s premises?
Yes
No If yes, give name:____________________________________
FORM # LLAPP (6/05)
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