Name: Intermarket Insurance Agency
Address: 205 East Main St, Huntington, NY, 11743, US
Telephone: (631) 421-2424

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
Email
This field is for validation purposes and should be left unchanged.

Carrier	Policy Period	Policy #	Losses Paid ($)	Losses Open ($)	Loss Description

Liquor Liability Application

Mandatory State Fraud Warnings

New Jersey

New York

Pennsylvania

Notice