Liquor Liability ApplicationPlease answer the following questions to the best of your ability. We understand that these are estimates. If you have questions, please call us at (641) 585-0510. Step 1 of 2 50% Applicant InformationApplicant's Name* Applicant's Email* Applicant's Phone*Location Address* Mailing Address* Website* Limits of Liability RequetedPer Occurrence: ($)* Aggregate: ($)* Proposed Policy Period From:* Proposed Policy Period To:* Name of Liquor License* Type of License* 1. Ownership Ownership Type Corporation Individual Partnership Other 2. Type of Establishment* Bar/Tavern Drive-through Daiquiri Shop Package Store Casino Gentle's/Strip Clubs Restaurant Catering Service Liquor Mfc/Microbrewery Wholesale/Distributor Comedy Club Night Clubs Convenience/Grocery Store 3. Do you provide entertainment as part of your operations? Yes No If yes, please check the applicable types of entertainment and answer the following questions: DJ Juke Box Live Entertainment Type and how often? Type of music played (By DJ, Juke Box or Live Entertainment) Rap/R&B Top 40s/POP Dancefloor Electronic Games Mechanical Bulls or Other Mechanical Devices Pool Table(s) Country/Western/Bluegrass Other Dance Floor Size: Electronic Game Type: Mechanical Device Type: Pool Tables # Are there any activities conducted that would involve patron participation and/or contract with patrons? Yes No If Yes, Please describe 4. Estimated liquor receipts: ($)* 5. Food Receipts: ($)* 6. Other receipts (excluding food & liquor) ($)* 7. Years in business* 8. Years at this location* 9. How many days per week is this location open?* 10. What time does this location close?* Hours of serving?* 11. Square foot area of establishment:* Maximum Occupancy* 12. Is this premises within city limits? Yes No 13. Located within 5 miles of college campus? Yes No 14. Is there a cover charge? Yes No If yes, what is the amount? ($)* 15. Do you have "Happy Hours," 2-for-1 drink specials or any other drink promotions? Yes No If yes, How often? 16. Is last call announce? Yes No If so, When?* 17. Are patrons allowed to bring their own alcohol? Yes No 18. Have you ever been assessed a fine for violation of a law concerning the sale of alcohol, or had your liquor license suspended? Yes No 19. Number of Servers: Describe you procedures and requirements for alcohol awareness training for servers: Type of Training: (Ex. TIPS, State Mandated, etc)Are all servers required to complete training? Yes No How often? 20. Types of clientele Area Residents College Area Workers Tourists Other List other types of clientele Are all servers required to complete the training? Yes No 21. Percentage of clientle (Under Age 25) (%)Please enter a number from 0 to 100.Ages 25-30 (%)Please enter a number from 0 to 100.Over Age 30 (%)Please enter a number from 0 to 100.Total percentage of clientele (must equal 100)Total percentage of clientele (must equal 100)Hidden21. Percentage of clientle (Under Age 25) (%) HiddenAges 25-30 (%) HiddenOver Age 30 (%) 22. Type of area Industrial or Commercial Area Workers Contracted Security Firms Doorman (Inside) Doorman (Outside) Off-duty Police (Armed) Off-duty Police (Unarmed) 24. Any firearms kept or carried on the premises? Yes No 25. In the last 5 years, have you had any claims or occurences that have resulted in or may give rise to a liquor liability claim? Yes No If yes, please describe the claim(s) below: 26. Do you enter into any contracts or agreements whereby you assume the liability of others? Yes No Please explain the nature of such contracts and agreements below: Any additional insureds being requested?* Yes No Provide Name, Address and Relation*Electronic Signature Agreement* By checking this box I acknowledge that the information I have entered is accurate and understand that the field above constitutes as my electronic signature. Revenue Audit I understand that written policies are subject to audit.We understand both the attendance and receipt values are estimated values. With that, we strongly encourage you to give the most accurate estimate as possible. By doing so, it allows us to provide you with a quote that is as reflective of your needs as possible. In addition, all policies are subject to an audit upon expiration. Therefore, providing the most realistic estimate as possible, not only allows us to provide the most accurate quote, but will also aide in reducing the possibility of a large discrepancy in these estimates when audited, which could potentially result in additional premium charges.NOTICE TO APPLICANT: The coverage applied for is solely as stated in the policy. If policy is issued on a "CLAIMS MADE" or "CLAIMS MADE AND REPORTED" basis, it provides coverage only for those claims that are first made against the insured during the policy period unless the extended reporting period option is exercised in accordance with the terms of the policy. If issued on an "OCCURRENCE" basis, the policy provides coverage only for those occurrences that take place during the policy period. The Insurer will rely upon this application and all such attachments in issuing the policy. If the information in this application or any attachment materially changes between the date this application is signed and the effective date of the policy, the Applicant will promptly notify the Insurer, who may modify or withdraw any outstanding quotation or agreement to bind coverage. In New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 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 and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. In all other states: It is a crime for any person to knowingly provide or facilitate in providing any false, incomplete, or misleading information to an insurance company. Penalties may include fines, imprisonment and denial of insurance benefits. WARRANTY: I warrant to the Insurer, that I understand and accept the notice stated above and that the information contained herein is true and that it shall be the basis of the policy of insurance and deemed incorporated therein, should the Insurer evidence its acceptance of this application by issuance of a policy. I authorize the release of claim information from any prior insurer to James River Insurance Company and its Subsidiaries, 6641 West Broad Street, Richmond, VA 23230. Please review all the following fields to ensure your information is accurate, then scroll down to the bottom of the page and click "SUBMIT".{all_fields}Section to be Completed by the Producer/Broker/AgentApplicant's Signature Producer's Signature Applicant's Name (Print) Producer's Name (Print) Date (MM/DD/YY) Date (MM/DD/YY) CAPTCHA
