Liquor Liability - Supplemental Application

Named Insured:*

Telephone:*

Email:*

Customer No./Policy No.

Effective Date:

General Information - If located in Illinois or Indiana, please contact Kevin Morency.

1. Type of Business:

Package StoreWholesale DistributorRestaurantOther (Describe)

Describe:

2. Type of Liquor Sold (check all that apply):

BeerWineLiquor

3. Are alcoholic beverages consumed on premises?

YesNo

3a. If yes, describe

4. Locations to be insured:

5. What is the Annual Gross Sales of Beer, Wine and Liquor?

6. Name and address of governmental authority that issued the current liquor license to named insured:

Prior Carrier (Previous Liquor Liability Policy)

Carrier

Policy Term:

Limit of Liability:

Underwriting Information (Explain all YES answers)

1. Has liquor liability insurance been declined, cancelled or non-renewed?

YesNo

1a. Please describe circumstances of past liquor liability claims.

2. Has there ever been a liquor liability claim made against the insured or circumstances that could result in a future claim?

YesNo

2a. Please describe circumstances of past liquor liability claims.

3. Has the applicant been cited for any liquor violations or had any permit/license suspensions or revocations?

YesNo

3a. If yes, please describe the previous violations, suspensions or revocations.

4. Does the insured have an ID checking procedure and posted age limits?

YesNo

5. Are all employees required to complete a training program?

YesNo

6. Does the insured deliver beer, wine or liquor to customers?

YesNo

6a. Explain.

SIGNATURE

The information I have provided is true and accurate to the best of my knowledge. I have not willfully concealed or misrepresented any material fact(s) or information. I understand completion of this questionnaire does not compel the company to provide coverage.

Signature

Or Enter Your Full Name As Signature:

Date:

Questions? 877-244-9090
Kevin Morency | kmorency@morencyinsurance.com

Morency & Associates Inc.
141 New Shackle Island Rd, Hendersonville, TN 37075
Fax: 615-452-6580

https://bedbreakfastinsurance.com/