Liquor Liability Application | Monoline

Please answer all questions completely. Completion of this application does not constitute coverage.

Monoline Liquor Liability Application

Complete this application to submit a monoline liquor liability risk to Conifer's commercial underwriting team. Have the following information ready before starting: Licensee details, operating hours, annual sales breakdown, entertainment and amenity details, and three years of prior carrier and claims history. Completing all fields reduces follow-up requests and speeds up the quoting process.

Step 1 of 6 - Agency Information

16%

Agency Information

Agency Name(Required)

Agency Code

Agent Contact Name(Required)

First Last

Phone

Email(Required)

Eligibility Notice

Monoline liquor liability coverage is available in Illinois, Indiana, Michigan and Ohio. If your risk is located outside of these states, please contact your Conifer representative for alternative options.

Policy Information

Target Date (Return to you by)(Required)

MM slash DD slash YYYY

Requested Effective Date(Required)

MM slash DD slash YYYY

Requested Expiration Date

MM slash DD slash YYYY

Applicant Information

Primary Named Insured(Required)

DBA

Business Type(Required)

Corporation

Individual

LLC

Joint Venture

Non-Profit

Partnership

Sole Proprietor

Trust

Other

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Billing Address(Required)

Same as Mailing Address

Street Address Address Line 2 City State ZIP Code

Applicant Phone(Required)

Applicant Email

Corporate Web Address

Inspection Contact(Required)

First Last

Inspection Phone Number(Required)

Is the applicant a member of any industry associations?(Required)

Yes

If yes, please list association(s):(Required)

Location Information

Location Address(Required)

Same as Mailing Address

Street Address Address Line 2 City State ZIP Code

Is this location seasonal?(Required)

Yes

Is this location a new venture?(Required)

Yes

What are the adjacent exposures?(Required)

Is this location open for business?(Required)

Yes

If not, what is the anticipated opening date?(Required)

MM slash DD slash YYYY

If yes, how long has the insured been in business at this location?(Required)

Description of Operations(Required)

Check all that apply for this location.

Bar or Tavern

Restaurant

Fine Dining

Fraternal Organization

Bowling Center

Convenience Store

Beer, Wine or Liquor Store

Brewery, Winery or Distillery

Billiard or Pool Hall

Gaming Parlor

Lounge (Cigar, Hookah, etc.)

Grocery Store

Gas Station

Comedy Club or Dinner Theater

Other

If other, please describe:(Required)

Operating Hours(Required)

Check all that apply for this location

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Monday Open(Required)

Monday Close(Required)

Tuesday Open(Required)

Tuesday Close(Required)

Wednesday Open(Required)

Wednesday Close(Required)

Thursday Open(Required)

Thursday Close(Required)

Friday Open(Required)

Friday Close(Required)

Saturday Open(Required)

Saturday Close(Required)

Sunday Open(Required)

Sunday Close(Required)

Building Occupancy

If the applicant is the only tenant in the building, enter 100% for Total Building.

% of Total Building(Required)

Please enter a number from 0 to 100.

% of Ground Floor(Required)

Please enter a number from 0 to 100.

% of Other Floors

Please enter a number from 0 to 100.

Property Details

Leave blank if not applicable to this location.

Total Area

Total Sq. Ft.

Area of Restaurant

Total Sq. Ft. (if applicable)

Area of Banquet Rooms

Total Sq. Ft. (if applicable)

# of Apartments

(if applicable)

Sales Information

Total sales should equal the sum of Total Liquor Sales, Total Food Sales and Other Sales.

Total Liquor Sales(Required)

Total Food Sales(Required)

Other Sales

Total Sales

Are the sales figures estimated or actual?(Required)

Estimated

Actual

Entertainment & Amenities

Check all that apply and complete the follow-up fields.

Entertainment & Amenities

Band

Dancing

Dart Boards

Juke Box

Karaoke

Keno

Pool Tables

Topless

Band - How many nights per week and type of music?(Required)

Dancing - How many nights per week?(Required)

Dart Boards - # of Dart Boards(Required)

Please enter a number less than or equal to 999.

DJ - How many nights per week and type of music?(Required)

Karaoke - How many nights per week?(Required)

Pool Tables - # of Pool Tables(Required)

Please enter a number less than or equal to 999.

Does this location sponsor athletic events?(Required)

Yes

If yes, please describe:(Required)

Premises Security

Does the applicant hire or utilize bouncers?(Required)

Yes

Liquor Liability Section

Licensee Name(Required)

Licensee Number(Required)

Liquor Liability

Please select the desired coverage limit(s).

Liquor Liability(Required)

$50,000 occurrence / $50,000 aggregate

$50,000 occurrence / $100,000 aggregate

$100,000 occurrence / $100,000 aggregate

$100,000 occurrence / $300,000 aggregate

$300,000 occurrence / $300,000 aggregate

$300,000 occurrence / $600,000 aggregate

$500,000 occurrence / $500,000 aggregate

$500,000 occurrence / $1,000,000 aggregate

$1,000,000 occurrence / $1,000,000 aggregate

Loss Control

Number of alcohol servers that are employed?(Required)

Please enter a number less than or equal to 999.

Number who are TIPS/TAMS certified?(Required)

Please enter a number less than or equal to 999.

Regulatory

Has the establishment been cited for a violation of any liquor laws in the past five (5) years?(Required)

Yes

If yes, please explain the violation(s):(Required)

Has liquor liability coverage ever been cancelled, declined, non-renewed or had a lapse in coverage?(Required)

Yes

If yes, please explain:(Required)

Risk History

Does the current liquor policy exclude assault or battery?(Required)

Yes

If not, what is the current Assault & Battery limit?

Does the current general liability policy exclude assault or battery?(Required)

Yes

If not, what is the current Assault & Battery limit?

Liquor Liability Prior Carrier Information

Liquor Liability Carrier

Policy Term From

Policy Term To

Insurance Carrier

Limit

Premium

Have there been any liquor liability claims at this location in the past three years?(Required)

Yes

Liquor Liability Claim History

Please list all claims or occurrences that may give rise to claims for the prior three years.

Liquor Liability Claims History

Date of Occurrence

Description of Loss

Claim Status

Amount Paid

Amount Reserved

Additional Claim Information - Liquor Liability

General Liability Prior Carrier Information

General Liability Carrier

Policy Term From

Policy Term To

Insurance Carrier

Limit

Premium

Have there been any general liability claims at this location in the past three years?(Required)

Yes

General Liability Claim History

Please list all claims or occurrences that may give rise to claims for the prior three years.

General Liability Claims History

Date of Occurrence

Description of Loss

Claim Status

Amount Paid

Amount Reserved

Additional Claim Information - General Liability

Agent / Broker Inspection

Has the agent or broker personally inspected this applicant’s location?(Required)

Yes

If yes, what is the condition of the risk?(Required)

Excellent

Good

Fair

Poor

Please provide any information that would be pertinent to this location:

Optional Attachment(s)

If available, please include loss runs, expiring policy or any other supporting documentation

Drop files here or

Max. file size: 16 MB, Max. files: 8.

Liquor Liability Application | Monoline

Monoline Liquor Liability Application

Agency Information

Policy Information

Applicant Information

Location Information

Liquor Liability Section

Risk History

Agent / Broker Inspection

ABOUT CONIFER

SERVICES

FOR AGENTS

RESOURCES