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
Required
|
|
| Last Name
Required
|
|
| Your contact Cell Phone?
Required
|
|
| What is your position in the company?
Required
|
|
| How did you hear about us?
Optional
|
|
| Company Legal & Contact Information |
| In what name do you conduct business?
Required
|
|
| Any other Owners?
Required
|
|
| Business Type?
Required
|
|
| FEIN number for Business
Required
|
|
| Year Established?
Required
|
|
| Website address?
Required
|
|
| Business Phone Number?
Required
|
|
| E-Mail Address
Required
|
|
| Street
Required
|
|
| City
Required
|
|
| State
Required
|
|
| ZIP / Postal Code
Required
|
|
| Is this the mailing or physical address of the business?
Required
|
|
| Information About Your Business |
| Liquor Licensee Name?
Required
|
|
| Seating Capacity?
Required
|
|
| Average Age of Clientele?
Required
|
|
| Is this a "college" bar?
Required
|
|
| Number of Bartenders?
Required
|
|
| Number of Servers?
Required
|
|
| Number of Bouncers?
Required
|
|
| Current Insurance Information |
| Do you currently have Liquor Liability Insurance?
Required
|
|
| When does OR did your coverage expire?
Optional
|
|
|
/ |
|
/ |
|
|
| Do you currently have General Liability Insurance?
Required
|
|
| When does OR did your coverage expire?
Optional
|
|
|
/ |
|
/ |
|
|
| Please describe any prior claims:
Optional
|
|
| Requested Coverage |
| General Liability Limits Requested
Required
|
|
| Privacy Policy
Optional
|
Click Here To View Our Privacy Policy |
Submission Validation Required |
Enter the Validation Code from above.
|
Important NoticeAny
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.
|