Bars / Restaurants / Taverns General Liability Application

PRINTABLE APPLICATION

BARS/RESTAURANTS/TAVERNS GENERAL LIABILITY APPLICATION

Applicant's Name:
Mailing Address:
City State Zip
Phone: Fax:

PROPOSED EFFECTIVE DATE:
From To
12:01 A.M. Standard Time at the address of the Applicant
Email Address:

Applicant is: Individual	Corporation	Partnership	Joint Venture
Other (Specify)

LIMITS OF LIABILITY REQUESTED

General Aggregate

Products & Completed Operations Aggregate

Personal & Advertising Injury

Each Occurrence

Fire Damage (any one fire)

Medical Expense (any one person)

$ Excluded

Other Coverages, Restrictions and/or Endorsements

Deductible

A. Classification of risk:
Tavern	Disco	Bowling Center	Caterer: Off premises On premises
Restaurant	Banquet facility	Membership Club	Country Club

B. Annual Sales
	Past 12 Months	Next 12 Months
Liquor Sales	$	$
Food Sales	$	$
Other	$	$
Total	$	$

C. Are surrounding premises:
Downtown District	Industrial	Seasonal	Rural	Resort
Waterfront	Suburban Commercial	Residential/commercial	Shopping Center
If waterfront, does applicant provide boat docking facilities for patrons? Yes No If yes, docking space for how many boats?

D. Clientele:
Local Residents	Families		Retirement Community
Median age of patrons:	18-25	25-30	30-40	40 and over
Are premises located near a college or university?

E. Entertainment
      Is there any live entertainment on premises Yes   No    Number of times per week
      If yes, describe (include go-go dancers, topless, disco, exotic, female/male):
      Is there dancing? Yes   No
      Does applicant have amusement devices? Yes   No     If yes, how many?

Describe:

Is there a minimum or cover charge? Yes No

Sports on premises? Yes No If yes, provide complete details:
Sports sponsored off premises? Yes No Number of times per week: Give details:

F. General Information
Are facilities available for use or rent for private parties, receptions, banquets or similar affairs? Yes No

If yes, number of times per year: Describe:

     Does applicant advertise or promote "happy hour" or other events when drinks are sold at a lower price
      than usual? Yes No
     Do you subscribe to a taxi or other service providing transportation home to apparently intoxicated patrons? Yes No

If yes, describe:

     Number of years under current management:   How many hours per day is applicant open?
     Type of meals served: Full Meals Short Order
     Maintenance of building is: Good Average Poor     Housekeeping Good Average Poor
     Does applicant have parking area? Yes No      Is lot well lit? Yes No
     In the past five years, has applicant been cited by the Liquor Control Commission? Yes No

If yes, give date(s) and full explanation:

   Are police records and background checks conducted on applicants? Yes No
     Number of bouncers or doormen   Are security/bouncers/doormen Employees Independent Contractors
     If independent contractors, do they provide Certificates of Insurance and Additional Insured Endorsements to our insured?
      Yes No
     Does applicant have Workers' Compensation coverage in force? Yes No
     Does applicant lease employees? Yes No
G. During the past 3 years, has any company ever cancelled, declined or refused to issue similar insurance to the applicant?
     Yes No

If yes, explain:

Previous Insurance: Indicate premium and losses for past three years. Describe all losses.
Year	Company	Policy #	Premium	Pd Losses	Res Losses	Description

SCHEDULE OF HAZARDS
Loc. No.	Classification	Class. Code	Premium Bases: (a) Gross Sales (p) Payroll (a) Area (c) Total Cost (t) Other	Terr

TRANSITION

1. Has this risk or any location not qualified for transition? Yes No
2. If this risk qualifies for transition, indicate year it first qualified:

Loc. No.	New Class. Code	Previous Basis	Previous Exposure	Applicable Coverage (Premises or Products

Application Completed By: Date:
Name and Phone Number of Individual to contact for Inspection/Audit: