Type of facility or event where liquor will be sold:
5.
Dates coverage required:
a. Opening and closing hours of event(s):
b. Opening and closing hours of liquor sales:
6.
Has applicant's liquor license ever been revoked or suspended? (Question is not applicable in Missouri)
Yes No
If Yes, please explain:
7.
Has applicant incurred claims for liquor liability during the last 3 years?
Yes No
If Yes, please explain:
8.
Has any insurer canceled or non-renewed coverage during the last 3 years? (Question is not applicable in Missouri)
Yes No
If Yes, please explain:
9.
Has applicant ever been fined by alcoholic beverage control or other governmental regulator?
Yes No
If Yes, please explain:
10.
Type of alcohol sold:
Beer
Wine
Wine Coolers
Mixed Drinks
11.
Annual Gross Sales:
Liquor Sales:
$
Food Sales:
$
Other:
$
12.
Are patrons allowed to carry alcoholic beverages onto the premises?
Yes No
If yes, what type?
13.
Do you exercise the right of search and seizure of contraband items?
Yes No
If yes, how do you notify the public of this?
14.
Do you maintain security personnel at entry checkpoints?
Yes No
If yes, what type?
15.
Are the alcohol sales and consumption:
Contained within one fixed site Booths/stands located throughout the event site
16.
Number of servers used:
Are minors allowed to enter the location where alcohol is being served?
Yes No
If yes, how is underage consumption of alcohol prevented?
17.
Do the servers receive any type of alcohol awareness training?
Yes No
If yes, please explain: (Attach a copy of training manual used)
18.
Median age of liquor customers:
19.
Are ID's checked for everyone purchasing alcohol?
Yes No
If no, please explain procedure:
20.
a. Are uniformed police officers present at the site of alcohol sales?
Yes No
If yes, how many?:
b. Is undercover security present?
Yes No
If yes, how many?:
c. Are contracted private security officers present?
Yes No
If yes, how many?:
21.
Are rules and regulations concerning alcohol consumption clearly displayed for patrons' viewing?
Yes No
22.
For beer sales, what size containers are used?:
Cupoz.
Pitcher
Other:
23.
Is there a limit placed on the quantity of alcoholic beverages purchased at one time per person?
Yes No
Explain:
24.
Is there entertainment provided?
Yes No
a. Live music?
Yes No
b. Disc Jockey?
Yes No
c. Type of Music:
25.
Is the parking area patrolled to prevent intoxicated drivers from leaving premises?
Yes No
Explain:
26.
Is there any type of designated driver program?
Yes No
Explain:
27.
Is there any other underlying liquor liability coverage being provided?
Yes No
Explain:
28.
Limit of liability requested:
$300,000 $500,000 $1,000,000 Other: $
STATEMENT FROM APPLICANT
I hereby represent and confirm that the above information, to the best of my knowledge, is true and correct and further certify that I have read all of the questions and answers of these applications.
NOTICE TO APPLICANT - PLEASE READ CAREFULLY
If the applicant has concealed or misrepresented any material fact, circumstance or fraud concerning this insurance resulting in deception to us which existed at the time of damage and contributed to such damage, this policy will be rendered void as long as the deception was material; was made knowingly with the intent to deceive; was relied and acted upon by the Insurer; and deceived the Insurer to the Insurer's injury.
Receipt and review of this application does not bind the Insurer to provide this insurance.
It is agreed by the applicant and the Insurer that the particulars and statements made in this application, together with all attachments to this application and any other materials submitted to the Insurer (all of which attachments and materials shall be deemed attached to the policy as if physically attached thereto) shall be the representations of the applicant and the prospective Insureds. It is further agreed by the applicant and the prospective Insureds that this policy, if issued, is issued in reliance upon the truth of such representations that are incorporated into and made part of this policy. After inquiry of all prospective Insureds, the undersigned authorized officer of the applicant represents that the statements set forth in this application and its attachments and other materials submitted to us are true and correct.
Signing of this application does not bind the applicant or the Insurer.
Inspections and Surveys: We have the right to make inspections and surveys at any time; give you reports on the conditions we find; and recommend changes. We are not obligated to make any inspections, surveys, reports or recommendations and any such actions we do undertake relate only to insurability and the premiums to be charged. We do not make safety inspections. We do not undertake to perform the duty of any person or organization to provide for the health or safety of workers or the public. We do not warrant that conditions are safe or healthful; or comply with laws, regulations, codes or standards.
The above applies not only to us, but also to any rating, advisory, rate service or similar organization which makes insurance inspections, surveys, reports or recommendations.
This condition does not apply to any inspections, surveys, reports or recommendations we may make relative to certification, under state or municipal statutes, ordinances or regulations, of boilers, pressure vessels or elevators.
The undersigned further declares that any event taking place between the date this application was signed and the effective date of the insurance applied for which may render inaccurate, untrue, or incomplete any information in this application, will immediately be reported in writing to us and we may withdraw or modify any outstanding quotations and /or authorization or agreement to bind the insurance.
Applicant Signature:
Title:
Email:
Date:
(MM/DD/YY)
Agent/Broker:
Address:
City:
State:
ZIP Code:
Telephone number:
-
I hereby represent and confirm that the above information, to the best of my knowledge, is true and correct and further certify that I have read all of the questions and answers of these applications. This email is certification that I am authorized to sign the application and having sent this email - consider this my signature.
NOTE: Please print out the application before clicking on the "Send" button for your own records.
FRAUD NOTICES - FOR APPLICANTS OF THE FOLLOWING STATES
ARKANSAS: Any person who knowingly presents a false or fraudulent claim for payment of a loss 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.
COLORADO: 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 policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder 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.
DISTRICT OF COLUMBIA: 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.
FLORIDA: 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 statement is guilty of a felony of the third degree.
KANSAS: A fraudulent insurance act means an act committed by 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 or 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 commercial or personal insurance, or a claim of payment or other benefit pursuant to an insurance policy for personal or commercial 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.
KENTUCKY: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing 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.
LOUISIANA: 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.
MAINE: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
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 MEXICO: 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 civil fines and criminal 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 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 violation.
OHIO: 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.
OKLAHOMA: 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 false, incomplete or misleading information is guilty of a felony.
OREGON: Any person who makes an intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law.
PENNSYLVANIA: 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 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.
TENNESSEE: 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.
VIRGINIA: 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.
The Monument Sports Group manages your insurance needs so that you can concentrate on growing your business.