Liquor - Stand Alone

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Applicant's Personal Contact Information

First Name *

Last Name *

Your contact Cell Phone? *

What is your position in the company? *

How did you hear about us?

Company Legal & Contact Information

In what name do you conduct business? *

Any other Owners? *

Business Type? *

FEIN number for Business *

Year Established? *

Website address? *

Business Phone Number? *

E-Mail Address *

Street *

City *

State *

ZIP / Postal Code *

Is this the mailing or physical address of the business? *

Information About Your Business

Liquor Licensee Name? *

Seating Capacity? *

Average Age of Clientele? *

Is this a "college" bar? *

Number of Bartenders? *

Number of Servers? *

Number of Bouncers? *

Current Insurance Information

Do you currently have Liquor Liability Insurance? *

When does OR did your coverage expire?

Do you currently have General Liability Insurance? *

When does OR did your coverage expire?

Please describe any prior claims:

Requested Coverage

General Liability Limits Requested *

$100,000/$200,000
$100,000/$300,000
$300,000/$300,000
$300,000/$600,000
$500,000/$500,000
$500,000/$1Mil
$1Mil/$1Mil
$1Mil/$2Mil

Click Here To View Our Privacy Policy

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

Insurance Websites Designed and Hosted by Insurance Website Builder