Nightclub Insurance Form

Client Information

Business Name Federal Tax ID #

Address

City, State, Zip AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY

Contact Name

Phone No. Ext Fax No.

Email Address

Effective Date/Renewal Date Years in Business

Annual Food Sales $ Annual Alcohol Sales $

Annual Cover Sales $ Annual Misc. Sales $

Establishment Details

Building Area (Sq. ft.) Number of Stories

Basement Select Yes No Adjacent Tenants Select Yes No

Building Construction Type and Age

Roof Construction Type and Age

Updates-years

Wiring Roofing

Plumbing Heating

Located within city limits? Select Yes No Distance to shoreline (miles)

Cooking Select Yes No If yes, ansul system

Covers: all foods? Select Yes No Deep Fat Fryers? Select Yes No

Open Flames? Select Yes No Service Contract for Cleaning? Select Yes No

Cleaning company name Date last cleaned

Auto fire extinguishing system? Select Yes No Security System Select Yes No

Name of Monitoring Co. No. of fire extinguishers

Sprinklered? Select Yes No Distance from fire hydrant

Distance from fire station

Hours of Operation: From To

M T W Th F Sat Sun

Is there entertainment? Yes No

What type & how often?

How many video games, pool tables, darts, etc?

Dancing? Select Yes No If yes, Sq. feet of dance floor

General Information

Any policy declined or cancelled during the prior three years? Yes No

Any bankruptcies, tax or credit liens against applicant in the past five years? Yes No

Is parking lot under insureds control? Select Yes No If yes, square footage

Is valet parking provided? Select Yes No If yes, employees or service?

Any incidents involving assault and battery in the past three years? Yes No

Number of bartenders/servers: Full-time Part-time

Do you have a formal written safety program? Yes No

Average age of clientelle? What is the seating capacity?

When is Happy Hour? Ladies Night?

What type of Certified training for bartenders and servers?

Coverage

Liability Amount Liquor Liability

Assault & Battery? Select Yes No Non-owned/hired auto? Select Yes No

Building Amount, $ Contents Amount, $

Tenant Improvements, $ Loss of Income $

Do you currently have insurance? Select Yes No Name of Insurer

Present Premium Policy #

Loss Information (Prior 5 years; dates & amounts)

Loss Payee Info

Additional Insured Info

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