ARCH SPECIALTY INSURANCE COMPANY (A Missouri Corporation)

Transcription

1 ARCH SPECIALTY INSURANCE COMPANY (A Missouri Corporation) Liquor Liability Application All questions must be answered, Application must be signed and dated by the applicant. 1. Name of Applicant: DBA Name (If different from Applicant): Name of Establishment Effective Date Requested (12:01 a.m.): mm/dd/yy (i.e. 10/25/13) 2. Establishment Location: Location Address 1 Street: Location Address 2 Street: City: State: Zip Code: Website (If applicable): 3. Applicant Mailing Address: (Check this box if Mailing address is the same as Location Address) Mailing Address 1 Street: Mailing Address 2 Street: City: State: Zip Code: 4. Liquor Liability Limits requested: Each Common Cause /Aggregate $100,000 / $100,000 $100,000 / $200,000 $300,000 / $300,000 $300,000 / $600,000 $500,000 / $500,000 $500,000 / $1,000,000 $1,000,000 / $1,000,000 $1,000,000 / $2,000, Approved Type of Risk: Underwriting Information: Bar / Tavern / Microbrewery Sports Bar Restaurant Hotel / Motel Liquor Mfg / Microbrewery off premises only Grocery Store Convenience Store / Delicatessen Wholesale / Distributor Liquor Store / Package Store Other (Describe) 06 ALL Page 1 of 7

2 6. a.)total estimated receipts: $ b.) Liquor receipts (Including Beer & Wine): $ c.) Food receipts: $ d.) Other receipts: $ 7. Has applicant been in business for less than one year? 8. Is alcohol served past 2:00a.m.? 9. Have you ever been assessed a fine or citation for violation of a law concerning the sale of alcohol? If, please describe nature of the violation and any corrective measures taken to prevent violations in the future: 10. Have you ever had your liquor license suspended? 11. Is the total capacity of the establishment more than 500 persons? 12. Have all servers been through formal alcohol server training within the past three (3) years that was provided by TIPS, TAM, TOPS, ABC, or ServeSafe or otherwise approved by the state s Alcohol Beverage Control or Liquor Control Board? If, please answer the following question: a.) Does the establishment have a ride home policy? 13. Does the establishment have standards and procedures in place regulating the sale of alcohol to minors or those under the influence? If, please answer the following questions: a.) Are those standards and procedures communicated to employees at least once a year? b.) Is a valid picture ID, issued by a public agency required to verify age of patrons? c.) Does the establishment use ID scanning machines to reduce the possibility of serving to minors? 06 ALL Page 2 of 7

3 14. Is any off premises catering being performed that requires the serving of liquor? If, please describe: 15. Is the establishment located within 2 miles of a college or university campus? If, please answer the following question: a) After 8:00pm, is the percentage of patrons under the age of 25 over 25%? 16. Does the establishment have Happy Hour, 2 for 1 drink specials or drink promotions? If, please answer the following questions: a) Are Happy Hours, 2 for 1 drink specials or drink promotions before 7:00 AM or after 10:00 PM? b) Do Happy Hours, 2 for 1 drink specials or drink promotions last more than three (3) hours? 17. With the exception of during drink specials or promotions, are the cost of drinks, including beer, below $2.00 per drink? 18. Are patrons allowed to BYOB (Bring Your Own Booze)? 19. Does the establishment provide any live entertainment more than three (3) times per week and/or lasting beyond 11:00 PM? If, please describe: 20. Does the establishment permit or sponsor alcohol consumption games (e.g. beer pong, flip cup, etc.) or permit the use of alcohol consumption enticing equipment (e.g. beer bongs, funnels, etc.)? 21. Does the establishment engage in any sponsored or non sponsored off premise events involving the serving of alcohol to the general public? 06 ALL Page 3 of 7

4 If, please describe: 22. Is there a dance floor? 23. Does the establishment allow any firearms to be kept or carried on the premises? 24. Does the establishment require patrons pass through a metal detector? Prior Insurance 25. During the past three (3) years, has the applicant had any Liquor Liability coverage declined, cancelled or non renewed? If yes, please provide details: 26. Has applicant incurred any Liquor Liability loss in excess of $50,000 or more than one (1) Liquor Liability loss over the past five (5) years? If yes, please provide details on the nature of the Claim and any corrective measures taken to prevent similar Claims in the future: 27. Prior Liquor Liability carrier: Each Common Cause Limits: Premium: $ $ Assault & Battery Coverage Only: THIS SECTION IS OPTIONAL. TO BE COMPLETED BASED ON ELIGIBILITY FOR ASSAULT & BATTERY 28. Assault & Battery Sub Limits Requested: If, please choose a sub limit of liability: 06 ALL Page 4 of 7

5 Each Common Cause / Aggregate $50,000 / $100,000 $100,000 / $200, Does the establishment employ any doormen, bouncers or a contracted security firm? 30. Does the establishment operate past 12:00 a.m.? 31. Has the applicant had any assault and battery claims or occurrences over the past five years? If yes, please provide details on the nature of the Claim or occurrence and any corrective measures taken to prevent similar Claims or occurrences in the future: 32. Does the applicant currently carry a Commercial General Liability Policy? If, please answer the following question: a) Is Assault & Battery specifically excluded from the Commercial General Liability policy? The Applicant declares that the information in this Application and in the materials submitted herewith is true, accurate and complete. Signing this Application does not bind the Applicant to purchase insurance, but it is agreed that this Application shall be the basis of any insurance policy issued. The information requested in this Application does not constitute notice under any insurance policy of a claim or potential claim. All claims notices must be submitted pursuant to the terms of the policy under which coverage is sought. If there is any change in the answers to the questions in this Application before the policy inception date, the Applicant must immediately notify the Insurer in writing. In such case, any outstanding quotation may be modified or withdrawn. NOTICE: ANY PERSON WHO, KNOWINGLY OR WITH INTENT TO DEFRAUD OR TO FACILITATE A FRAUD AGAINST ANY INSURANCE COMPANY OR OTHER PERSON, SUBMITS AN APPLICATION OR FILES A CLAIM FOR INSURANCE CONTAINING FALSE, DECEPTIVE OR MISLEADING INFORMATION MAY BE GUILTY OF INSURANCE FRAUD. 06 ALL Page 5 of 7

6 NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution or confinement in prison, or any combination thereof. NOTICE TO ARKANSAS, LOUISIANA AND NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an Insurance Company for the purpose of defrauding or attempting to defraud the Company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any Insurance Company or agent of an Insurance Company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony in the third degree. NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with the intent to defraud any Insurance Company or other person files an application for insurance 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. NOTICE TO MAINE, TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an Insurance Company for the purpose of defrauding the Company. Penalties include imprisonment, fines and denial of insurance benefits. NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. NOTICE TO NEW YORK APPLICANTS: 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. 06 ALL Page 6 of 7

7 NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. NOTICE TO OREGON APPLICANTS: Any person who, knowingly and with intent to defraud or facilitate a fraud against any insurance company or other person, submits an application, or files a claim for insurance containing any false, deceptive, or misleading material information may be guilty of insurance fraud. NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with the 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 subjects such person to criminal and civil penalties. NOTICE TO PUERTO RICO APPLICANTS: Any person who knowingly and with the intent to defraud, presents false information in an insurance request form, or who presents, helps, or has presented a fraudulent claim for the payment of a loss or other benefit, or presents more than one claim for the same damage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine of no less than five thousand dollars ($5,000) nor more than ten thousand dollars ($10,000); or imprisonment for a fixed term of three (3) years, or both penalties. If aggravated circumstances prevail, the fixed established imprisonment may be increased to a maximum of five (5) years; if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. NOTICE TO ALL APPLICANTS: The signer of this application acknowledges and understands that the information provided in this Application is material to the Insurer s decision to provide the requested insurance and is relied on by the Insurer in providing such insurance. The signer of this application represents that the information provided in this Application is true and correct in all matters. The signer of this Application further represents that any changes in matters inquired about in this Application occurring prior to the effective date of coverage, which render the information provided herein untrue, incorrect or inaccurate in any way will be reported to the Insurer immediately in writing. The Insurer reserves the right to modify or withdraw any quote or binder issued if such changes are material to the insurability or premium charged, based on the Insurer s underwriting guides. The Insurer is hereby authorized, but not required, to make any investigation and inquiry in connection with the information, statements and disclosures provided in this Application. The decision of the Insurer not to make or to limit any investigation or inquiry shall not be deemed a waiver of any rights by the Insurer and shall not estop the Insurer from relying on any statement in this Application in the event the Policy is issued. It is agreed that this Application shall be the basis of the contract should a policy be issued, and it will be attached and become a part of the Policy. This Application must be signed by the Applicant: Date: Applicant Signature: 06 ALL Page 7 of 7