Please complete all sections of this application

Name of Applicant

First Last

Mailing address:

Phone number:

Email address:

Inspection contact name:

Audit contact name:

Do you have a website?

Yes

No

If yes, provide the website address:

The applicant is:

Individual

Partnership

Corporation

Other

Is this a Non Profit Private, Fraternal or Social Club?

Yes

No

Are same-day memberships available?

Yes

No

Is this risk located in a dry country or township?

Yes

No

Are members permitted to bring more than 2 guests per day (excluding banquet activities and immediate family members)?

Yes

No

Is self service of alcohol permitted by members?

Yes

No

Number of locations to be insured (complete 1 application per location):

Location address:

How long has current owner been operating at this location?

If 5 years or less, describe experience:

Has applicant ever operated this location under a different name or DBA (other than above)?

Yes

No

If yes, provide name or DBA used:

Does applicant ever sell or serve alcohol away from the premises?

Yes

No

What is the latest hour the establishment will ever stay open?

What time does the sale or service of alcohol cease?

If open past 2:00 AM, is a special license required to stay open late?

Yes

No

For Minnesota risks only: Does applicant have a special license to stay open past 1:00 AM?

Yes

No

Prior Policy

Prior Policy Date

_______ to ________

Carrier Name

Coverage Type: Liab/PHD/MTC

POLICY #

# of Units Insured

Any loses within the past 5 years?

If YES please upload on the related documents attaching box below.

Amount Paid

Driver Involved in Loss

Upload Your Current Insurance Policy or Related Documents

Drop files here or

Max. file size: 20 MB, Max. files: 10.

Fraud Statement:

Any person who knowingly and with the intent to defraud any insurance company or other person, files and 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 may subject such person to criminal and/or civil penalties and other sanctions.

Applicant’s Warranty Statement:

The undersigned represents to the best of his/her knowledge and belief the particulars and statements set forth are true and agree that those particulars and statements are material to the acceptance of the risk assumed by the Company. The undersigned further declares that any claim, incident or event taking place prior to the effective date of the insurance applied for which may render inaccurate, untrue, or incomplete any statement made will immediately be reported in writing to the Company and the Company may withdraw or modify andy outstanding quotations and/or authorization or agreement to bind the insurance. The signing of the Application does not bind the undersigned to purchase the insurance, nor does the review of the Application bind the Company to issue a policy. It is understood the Company is relying on the Application in the event the Policy is issued. It is agreed that this Application, including any material submitted there with, shall be the basis of the contract should a policy be issued, and may be attached to and become part of the policy.

Virginia Notice:

Statements in the application shall be deemed the insured’s representations. A statement made in the Application or in any affidavit made before or after a loss under the policy will be deemed material or invalidate coverage unless it is clearly proven that such statement was material to the risk when assumed and was untrue.

Minnesota Notice:

The clause “and/or authorization or agreement to bind the insurance” is replaced with “authorization or agreement to bind the insurance may be withdrawn or modified based on changes to the information contained in this application prior to the effective date of the insurance applied for may render inaccurate, untrue or incomplete any statement made with the minimum of 10 days notice given to the insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for non payment of premium.”