PO BOX 9007

LONG BEACH, NY 11561-9007
PHONE: (516) 825-2800

FAX: (516) 825-1947
UNDERWRITING EMAIL: clpapps@lancerinsurance.com
LIQUOR LIABILITY APPLICATION
(COMPLETE IN ADDITION TO ACORD GENERAL LIABILITY APPLICATION)
Applicants Name
Agent Name
Mailing Address
Address
Location #1
PROPOSED EFFECTIVE DATE:
Complete a separate application for each location.
From
To
12:01 A.M., Standard Time at the address of the Applicant
LIMITS OF LIABILITY REQUESTED
Each Common Cause
Aggregate
$
$
PLEASE ANSWER ALL QUESTIONS
1.
Type of risk:
Bar/Tavern
Night Clubs
Restaurant
Gentlemen’s/Strip Clubs
Liquor Manufacturer/Microbrewery
Other (Describe)
2.
Have you ever been assessed a fine for violation of a law concerning the sale of alcohol, or had your liquor
license suspended? …………………………………………………………………………………………
Yes
No
If Yes, when and why?
3.
Name on liquor license
4.
Have all servers been through any server training (tips, tops)? ..................................................
Type of course
How often required?
5.
Number of employees (bartenders, servers, cooks, etc)
6.
Procedures in place regulating the sale of alcohol to minors or those under the influence?
If Yes, describe:
How is age of customer verified?
7.
Type of clientele:
8
Percent of clientele:
9.
Located on or near college campus? ……………………………………………………………………
10.
How many years has applicant been in business?
11.
How many years has applicant been at this location?
12.
How many days per week is location open?
13.
Is there any bottle service?……………………………………………….…………………………........
Liquor Liability Application 12/13
Area Residents
Under 25
Area Workers
%
25-30
Tourists
%
College
Over 30
Yes
No
Yes
No
Yes
No
Yes
No
Other
%
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14.
Are patrons allowed to mix their own drinks? …….................………………………………………
Yes
No
15.
Are patrons allowed to BYOB (Bring Your Own Booze)? ……………………………………………
Yes
No
16.
Type of security:
Bouncers
Doorman
Off Duty Policy
Contracted Security Firms:
inside
outside
armed
unarmed
Any firearms kept or carried on the premises? ………………………………………………………..
Yes
No
Yes
No
17.
Types of entertainment activities:
Live Entertainment
Type and how often?
DJ
Dance Floor Size
Juke Box
Pool Table(s)
Number:
Electronic Games
Type:
Mechanical Devices
Type:
Other activities that would include patron participation (such as: wrestling, boxing, volleyball, etc.):
Special Promotions
Yes
No If Yes, describe
18.
Estimated liquor receipts: $
Other receipts:
$
19.
Estimated food receipts:
20.
Prior carrier:
21.
Has applicant had any claims? ……………………………………………………………………………
If Yes, give details:
$
Policy number:
MANDATORY STATE FRAUD WARNINGS
NEW JERSEY: “Any person who includes any false or misleading information on an application for an insurance policy is
subject to criminal and civil penalties.”
NEW YORK: “Any person who knowingly and with intent to defraud any insurance company or other person files an
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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each
such violation.”
PENNSYLVANIA: “Any person who knowingly and with intent to injure or defraud any insurer files an application or
claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for
up to seven years and payment of a fine of up to $15,000.”
I understand that Liquor Liability is a separate coverage part and the limits requested in this application apply solely to
liquor liability coverage and may differ from the General Liability limits afforded in my commercial package policy.
I further understand that the Company is relying upon statements I have made in this application as an inducement to
provide insurance for Liquor Liability coverage.
Named Insured Signature
Date
Producing Agent Signature
Date
Liquor Liability Application 12/13
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