Corporate and DBA Name
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Name
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First Name
Last Name
Email Address
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Phone Number
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Physical Address of Business
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Mailing Address
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County Located in
FEIN/Social Security #
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Date you started your business at this location
MM
DD
YYYY
Number of Full-Time Employees
Number of Part-Time Employees
Do you own or lease the building?
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Effective renewal date of Insurance Policy
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MM
DD
YYYY
Square footage of Building
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Building Square Footage open to public?
Maximum Legal Capacity
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Does your business have any stages or elevated platforms?
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Yes
No
Distance to Ocean/Water?
Parking Lot?
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Square Footage of Parking Lot
New Venture?
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Do you have a Central Fire Alarm System?
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Yes
No
Do you have a Central Burglar Alarm System?
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Yes
No
Is the building sprinklered?
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Number of surveillance cameras inside?
Number of surveillance cameras outside?
Do you store video footage for a minimum of 60 days?
Most carriers require this now
Does Location have any of the following exposures?
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check all that apply
Hours of operation: Days?
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Hours of operation: Time?
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Will the applicant be closed for business for a period greater than 21 consecutive days?
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Has the applicant ever been cited for health code violations in the past 3 years?
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Will the applicant be involved in any special events or other activities away from location?
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If yes, please list Name of Event(s), Date of Event(s), Description and all Additional Insured(s) required to be listed for event(s):
Does the applicant provide off-premise catering services?
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Does applicant have an employee handbook?
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Does the applicant rent or lease the venue for private parties?
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Who is your Current Insurance Carrier?
What is Current Price of your Insurance Policy?
Description of Operation
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Entertainment:
Music Genres for Live Concerts
check all that apply
Does your business contain:
check all that apply
Do you permit or allow dancing?
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Size of Dance Floor?
Does the applicant have a swimming pool, suana, or hot tub on premise?
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Will the applicant allow, permit or hold pyrotechnic displays on premise
*
Does the applicant have a valid liquor license?
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Provide name and Liquor License #
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*Has applicant ever been cited for liquor violation?
*Has the applicant or any owner, partner or member ever had a liquor license suspended or revoked?
*Does the applicant manufacture alcohol on premises?
*Does the applicant require all alcohol servers to have a valid certificate from an accredited or recognized alcohol awareness training program?
Name of Certification Program?
*
*Does the applicant allow employees or contractors to consume alcohol while working?
*Does the applicant allow employees or contractors to consume alcohol after their work shift?
*Does the applicant allow employees or contractors to consume alcohol after their work shift on premise?
*Does the applicant have bottle service or the sale of whole bottles of hard liquor to a table?
*Does the applicant allow or permit BYOB on premise?
*Does the applicant ever offer flaming or ignited drinks?
*Does the applicant serve drinks including liquid nitrogen?
*Does the applicant subscribe to any program or provide any form of available 3rd party transportation
*Will the applicant ever allow or sponsor drinking Olympics or any form of drinking games?
*Will the applicant ever allow or sponsor the use of equipment to entice patrons to drink faster, Such as beer bongs or funnels?
*Will the applicant allow patrons under the age of 21, but over the age of 18 on premises in the evening?
*Will the applicant use wristbands with all patrons over the age of 21 when allowing patrons over 18 on premise?
*Will the applicant allow patrons under the age of 18 or allow and/or sponsor teen night?
*Will the applicant ever hold or allow Foam Parties on premises?
*Does the applicant offer Happy Hour?
*Will the applicant offer any drink prices reduced to less than a $1.00?
Is Last Call Given?
Yes
No
Does the applicant have cooking on premesis?
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Yes
No
If yes, is the cooking area, hood and duct system protected by a fire extinguishing system?
Yes
No
Does the applicant have security, bouncers, and/or doormen?
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Yes
No
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Are Security, Bouncers, ID Checker:
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Does the applicant perform background checks on all Security, Bouncers, Door People, or ID Checkers?
Will the applicant ever employ Security personnel with prior convictions for assault and/or battery?
IF Contractors, does the applicant have a written agreement with Security Contractor?
If Contractors, does the security company provide a certificate of insurance evidencing equal General Liability limits and listing the applicant as their landlord as Additional Insureds?
Any claims in the last 5 years? If so, please explain
If Contractors, does the applicant allow security to carry any form of weapons?
If yes, please provide detailed explanation:
Will the applicant ever engage policy officers to be on premise?
Is the location currently under or are there any plans for construction or renovation?
If yes, please provide detailed explanation
Is the location within 5 miles of a college or university?
Are all cooking devices installed with a minimum of 18” safe clearances to combustible surfaces?
UL 300 listed auto fire extinguishing system provides surface protection for all cooking surfaces?
Are all gas equipment and deep fat fryers equipped with automatic fuel shut off?
All hoods and ducts cleaned every 6 months by a contractor under an agreement?
Are automatic fire extinguishing systems serviced no less than every 6 months?
Does the insured sub-lease any or all kitchen services to another entity?
Is there lighting?
Does the insured charge a fee for parking?
Will the insured hold special events or other functions in the parking lot?
Construction of Building?
Number of stories?
Year built
What are the adjacent exposures
# of Apartments in building?
Landlord Name:
Landlord Address:
Which coverages are being requested?
*
Please select all that apply
Are there any individuals or entities that need to be listed as an Additional Insured to the policy? If yes, please provide the name and address below:
Does your lease require the following:
Select all that apply to your lease requirements
Additional Notes:
