Skip to the content

Intermarket Insurance Agency(opens in new tab)

Insurance
EDU-PRO
About
Policy Service
Contact

Home > Liquor Liability Application

Liquor Liability Application

Your Name*
Email*
Phone*
Legal Business Name*
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Proposed Effective Date From
MM slash DD slash YYYY

12:01 AM Standard Time at the Address of the Applicant.
Proposed Effective Date To
MM slash DD slash YYYY

12:01 AM Standard Time at the Address of the Applicant.
Type of Risk*
- Bar/Tavern
- Restaurant
- Liquor Manufacturer/Microbrewery
- Night Club
- Gentleman's/Strip Club
Have you ever been assessed a fine for violation of a law concerning the sale of alcohol, or had your liquor license suspended?*
- Yes
- No
If Yes, when and why?
Name on Liquor License*
Have all servers been through any server training (tips, tops)?*
- Yes
- No
If Yes, list type of course and how often the course is required.
Number of Employees (Bartenders, Servers, Cooks, etc.)*
Are procedures in place regulating the sale of alcohol to minors or those under the influence?*
- Yes
- No
If Yes, please describe.
How is age of customer verified?*
Type of Clientele*
- Area Residents
- Area Workers
- Tourists
- College
- Other
List Percentage of Clientele*
Under 25 25 - 30 Over 30
Located on or near college campus?*
- Yes
- No
How many years has applicant been in business?*
How many years has applicant been at this location?*
How many days per week is location open?*
Is there any bottle service?*
- Yes
- No
Are patrons allowed to mix their own drinks?*
- Yes
- No
Are patrons allowed to BYOB (Bring Your Own Booze)?*
- Yes
- No
Type of Security*
- Bouncers
- Doorman
- Off Duty Police
- Contracted Security Firm (Inside)
- Contracted Security Firm (Outside)
- Contracted Security Firm (Armed)
- Contracted Security Firm (Unarmed)
Any firearms kept or carried on the premises?*
- Yes
- No
If you offer live entertainment, please list the type and how often.
Do you have a juke box?*
- Yes
- No
Do you ever have live DJs?*
- Yes
- No
Do you have a dance floor?*
- Yes
- No
If Yes, Dance Floor Size*
Do you have pool tables?*
- Yes
- No
If Yes, Number of Pool Tables*
Do you offer electronic games?*
- Yes
- No
If Yes, please describe.
Do you have any entertainment devices?*
- Yes
- No
If Yes, please describe.
Describe any other activities that would include patron participation (such as wrestling, boxing, volleyball, etc.).
Please describe any special promotions.
Estimated Liquor Receipts ($)*
Other Receipts ($)*
Estimated Food Receipts ($)*
Do you have prior coverage?*
- Yes
- No
If Yes, Prior Carrier*
If Yes, Prior Policy Number*
If Yes, has applicant had any claims in the last 3 years?*
- Yes
- No
If Yes, please list all claims from last 3 years.
Carrier Policy Period Policy # Losses Paid ($) Losses Open ($) Loss Description
Mandatory State Fraud Warnings
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 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 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.
Pennsylvania
Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and a payment of a fine of up to $15,000.
Notice
By providing your electronic signature below, you agree that you understand the following:

I understand that Liquor Liability is a separate coverage part and the limits requested in this application apply solely to liquor liability coverage and may differ from the General Liability limits afforded in my commercial package policy.

I further understand that the Company is relying upon statements I have made in this application as an inducement to provide insurance for Liquor Liability coverage.
Named Insured Signature*
Date*
MM slash DD slash YYYY

Save and Continue Later

Δ

We Want Your Opinion!

Write a Review(opens in new tab)

Customer Reviews

HA

Intermarket Insurance Agency was there when we needed them!Homer a., Our Smart Place, L.L.C., Ocala, FL

EC

They are upbeat, quick to respond, and just an overall joy to work with.Ed C., Summit Learning Services, Plantation, FL

CH

I have already referred Intermarket and Vicky to another provider.Carole H., Sunshine State Star Students, LLC, Longwood, FL

KM

...thank you for an excellent customer service experience.Kraig M., Who Got Game, Stuart, Florida

CJ

You saved the day for us.Claudette J., New Life Child Care and Educational Center, Lauderdale Lakes, Florida

See All Reviews See All Reviews

Contact

Intermarket Insurance Agency

205 East Main St
Suite 3-4
Huntington, New York 11743

Phone: (631) 421-2424

Fax: (631) 421-2004

Mon-Thu: 9:00am-5:00pm
Fri: 8:30am-4:30pm
Sat-Sun: Closed

Google Maps Logo (opens in new tab)Yelp Logo (opens in new tab)Facebook Logo (opens in new tab)X Logo (opens in new tab)Instagram Logo (opens in new tab)

Insurance

Auto, Home, & Personal Insurance
Business Insurance

About

About Us
Meet Our Staff
Our Insurance Carriers
Customer Reviews
Our Agency Partners

Policy Service

Policy Service Center
File a Claim
Online Billing & Payments
Request a Certificate
Policy Change Request

Intermarket Insurance Agency Provides Auto/Car Insurance, Homeowners Insurance and Business/Commercial Insurance to All of New York, Including Huntington, Long Island, and Hempstead.

© Copyright 2024, Intermarket Insurance Agency | Privacy Statement | Accessibility Statement | Login

Insurance Web Design(opens in new tab)