About Your Business
Location Address (if different):
City:	State:   Zip:
How Long at This Location:	years   Years in Business: years
Name On License:
Effective Date Requested:	Expiration Date:

Type of Operation

Select All That Apply

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). Other (describe in detail below).

Miscellaneous Information

Do you dispense or provide alcoholic beverages for any events off-premises?:   yes  no     If yes, describe below:

Name of person who keeps the books:   Phone #:

Sales Information

Past 12 months 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: Happy Hour Nights Per Week: Other:

Miscellaneous Information
Hours of Operation
Sunday ampm to ampm Closed Closed Part of Day Monday ampm to ampm Closed Closed Part of Day Tuesday ampm to ampm Closed Closed Part of Day Wednesday ampm to ampm Closed Closed Part of Day Thursday ampm to ampm Closed Closed Part of Day Friday ampm to ampm Closed Closed Part of Day Saturday ampm to ampm 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 Co.:
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 below:
Applicant of any other owner, partner or licensee ever had a liquor license revoked or suspended:	yes no   If yes, provide details below:

Additional Comments

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