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CGA Liquor Liability Quote Form
We would like to provide you with a free, no-obligation Liquor Liability insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Submitting Information
Business Name:
Contact Name:
Street Address:
City:   State:   ZIP:
County:   Email:
Business Phone: Fax:
General Information
Name of Business:
Contact Name:
Mailing Address:
City:   State:   Zip:
Business Phone:   Fax:
Best Time To Call:   AM   PM
Contact Email Address:


About Your Business
Location Address (if different):
City:   State:   Zip:
How Long at This Location: years               Years in Business: years
Name On License:
Effective Date Requested:    Expiration Date:



Type of Operation
Select All That Apply
  1. Tavern or bar without entertainment and annual alcohol beverage receipts over $250,000.
  2. Tavern or bar with entertainment nightclub.
  3. Tavern or bar without entertainment and annual alcohol receipts under $250,000.
  4. Restaurant (over 50% food), hotel, motel, or private club that serves food.
  5. Private Club (no food).
  6. Package liquor store, convenience store or gas station.
  7. Manufacturer, wholesaler, or distributor.
  8. Special event (include supplemental application).
  9. Other (describe in detail below).
Miscellaneous Information
Do you dispense or provide alcoholic beverages for any events off-premises?:   yes   no
If yes, describe:
Name of person who keeps the books:   Phone:
Sales Information
Past 12 months Next 12 months
Estimated Sales: $ $
Gross Sales Other: $ $
Gross Alcohol Sales: $ $


Coverage Information
Primary Limits Desired: $ Each Common Cause: $
Aggregate: $ Prior Policy Limits: $
Previous Coverage Information
Previous Liquor Liability Carrier:
Premium: $ Limits: $
Policy Number:   Effective Dates:  


Underwriting Information
LIABILITY
Seating Capacity:
Dining Room: Bar: Outside Deck/Patio: Other:
Does your establishment have any of the following (check all that apply):
Pinball Machines How Many: Days Per Week:
Video Games How Many: Days Per Week:
Pool Tables How Many: Days Per Week:
Juke box  
Dock/Deck Area  
Other:  
Does your establishment offer any entertainment (check all that apply):
Rock & Roll Nights Per Week:
Disco Nights Per Week:
Band Nights Per Week:
Country Western Nights Per Week:
Piano Nights Per Week:
Juke Box Nights Per Week:
Topless Girls Nights Per Week:
Dancing Nights Per Week:
Happy Hour Nights Per Week:
Other:


Miscellaneous Information
Hours of Operation
Sunday to       Closed       Closed Part of Day
Monday to       Closed       Closed Part of Day
Tuesday to       Closed       Closed Part of Day
Wednesday to       Closed       Closed Part of Day
Thursday to       Closed       Closed Part of Day
Friday to       Closed       Closed Part of Day
Saturday to       Closed       Closed Part of Day
Employee Information
Number of employees (per shift):  1st Shift     2nd Shift     3rd Shift
Number of bouncers / security:  Bouncers     Security


Current / Previous Insuror
Current/Previous Insurance Company:    
Policy Number:          Expires:
Premium for package policy:   $     Limits: $
Is general liability coverage carried:     yes   no
Applicant ever had insurance
cancelled or non-renewed:		     yes   no     If yes, provide details below:
Applicant of any other owner, partner or licensee ever had a liquor license revoked or suspended:     yes   no     If yes, provide details below:


Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.

 
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