Liquor Liability Our process is transparentFor Help Call 1-(248)-856-9000 GENERAL INFORMATION Fields marked (*) are mandatory NAME OF BUSINESS CONTACT NAME MAILING ADDRESS CITY STATE Please select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP BUSINESS PHONE FAX BEST TIME TO CALL CONTACT EMAIL ADDRESS ABOUT YOUR BUSINESS LOCATION ADDRESS CITY STATE Please select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP HOW LONG AT THIS LOCATION (YEARS) YEARS IN BUSINESS NAME ON LICENSE EFFECTIVE DATE REQUESTED EXPIRATION DATE TYPE OF OPERATION TAVERN OR BAR WITHOUT ENTERTAINMENT AND ANNUAL ALCOHOL BEVERAGE RECEIPTS OVER $250,000 TAVERN OR BAR WITH ENTERTAINMENT NIGHTCLUB TAVERN OR BAR WITHOUT ENTERTAINMENT AND ANNUAL ALCOHOL RECEIPTS UNDER $250,000 RESTAURANT (OVER 50% FOOD), HOTEL, MOTEL, OR PRIVATE CLUB THAT SERVES FOOD PRIVATE CLUB (NO FOOD) PACKAGE LIQUOR STORE, CONVENIENCE STORE OR GAS STATION MANUFACTURER, WHOLESALER, OR DISTRIBUTOR SPECIAL EVENT (INCLUDE SUPPLEMENTAL APPLICATION) IF OTHER MISCELLANEOUS INFORMATION DO YOU DISPENSE OR PRO VIDE ALCOHOLIC BEVERAGES FOR ANY EVENTS OFF-PREMISES? Yes No IF YES, DESCRIBE NAME OF PERSON WHO KEEPS THE BOOKS PHONE SALES INFORMATION (PAST 12 MONTHS) ESTIMATED SALES GROSS SALES OTHER GROSS ALCOHOL SALES SALES INFORMATION (NEXT 12 MONTHS) ESTIMATED SALES GROSS SALES OTHER GROSS ALCOHOL SALES COVERAGE INFORMATION PRIMARY LIMITS DESIRED EACH COMMON CAUSE AGGREGATE PRIOR POLICY LIMITS PREVIOUS COVERAGE INFORMATION PREVIOUS LIQUOR LIABILITY CARRIER PREMIUM LIMITS POLICY NUMBER EFFECTIVE DATES Underwriting Information LIABILITY Seating Capacity DINING ROOM BAR OUTSIDE DECK/PATIO OTHER Does your establishment have any of the following (check all that apply) Pinball Machines HOW MANY DAYS PER WEEK Video Games HOW MANY DAYS PER WEEK Pool Tables HOW MANY DAYS PER WEEK JUKE BOX DOCK/DECK AREA OTHER Does your establishment offer any entertainment (check all that apply) ROCK & ROLL NIGHTS PER WEEK DISCO NIGHTS PER WEEK BAND NIGHTS PER WEEK COUNTRY WESTERN NIGHTS PER WEEK PIANO NIGHTS PER WEEK JUKE BOX NIGHTS PER WEEK TOPLESS GIRLS NIGHTS PER WEEK DANCING NIGHTS PER WEEK HAPPYHOUR NIGHTS PER WEEK OTHER MISCELLANEOUS INFORMATION Hours of Operation Sunday FROM TO CLOSED CLOSED PART OF DAY Monday FROM TO CLOSED CLOSED PART OF DAY Tuesday FROM TO CLOSED CLOSED PART OF DAY Wednesday FROM TO CLOSED CLOSED PART OF DAY Thursday FROM TO CLOSED CLOSED PART OF DAY Friday FROM TO CLOSED CLOSED PART OF DAY Saturday FROM TO CLOSED CLOSED PART OF DAY EMPLOYEE INFORMATION Number of employees (per shift): 1ST SHIFT 2ND SHIFT 3RD SHIFT Number of bouncers / security BOUNCERS SECURITY Current / Previous Insuror CURRENT/PREVIOUS INSURANCE COMPANY POLICY NUMBER EXPIRES PREMIUM FOR PACKAGE POLICY LIMITS IS GENERAL LIABILITY COVERAGE CARRIED Yes No APPLICANT EVER HAD INSURANCE CANCELLED OR NON-RENEWED Yes No IF YES, PROVIDE DETAILS APPLICANT OF ANY OTHER OWNER, PARTNER OR LICENSEE EVER HAD A LIQUOR LICENSE REVOKED OR SUSPENDED Yes No IF YES, PROVIDE DETAILS ADDITIONAL COMMENTS ADDITIONAL COMMENTS Send