INSURANCE AGENCY 15 VILLAGE SQUARE CENTER, ST LOUIS, MO 63042 314-731-1400 800-926-6901

BEST CHOICE

WARRANTY APPLICATION
INSTRUCTIONS: All questions must be answered. This application must he signed and dated by an owner, officer or partner. Read carefully the statements at the end of this application.
New Renewal If a renewal, provide expiring policy number:
1	Name of Applicant
	DBA
2	Mailing Address
3	Location
4	The applicant is:	Individual Partnership Corporation Other
	If "Other", describe:
5	Name on Liquor License:
6	Name of person who keeps books:
	Phone:
7	How long has current owner been in business at this location? If 5 years or less, describe prior experience:
8	Has owner, officer or partner filed bankruptcy in the last 5 years?		Yes No
	If yes, explain:
9	TYPE OF BUSINESS:	If "Other"
ESTIMATED RECEIPTS

10	a.)	Total Gross Annual Receipts	Past 12 Months	Next 12 Months
		FOOD	$	$
		ALCOHOL	$	$
		OTHER	$	$
	b.)	If applicant engages in the sale of alcoholic beverages for on-premises & off-premises consumption, provide a breakdown:
			On Premise	Off Premise
		FOOD	$	$
		ALCOHOL	$	$
	c.)	If applicant has more than one operation at same location, provide breakdown of receipts by operation;
			Bar/Lounge	Restaurant
		FOOD	$	$
		ALCOHOL	$	$
		OTHER	$	$
			Banquet	Retail Sales
		FOOD	$	$
		ALCOHOL	$	$
		OTHER	$	$
			Other
		FOOD	$
		ALCOHOL	$
		OTHER	$

11	Does applicant feature any ENTERTAINMENT?			Yes No
	If yes: a.)	How many times PER YEAR?
	b.)	How many times PER WEEK?
	c.)	Type of entertainment featured:
		Band (1-3 members)	Band (4+members)	Comedy Club
		DJ	Exotic Dancers/Adult Entertainment
		Jukebox	Karaoke	Solo Vocalist
		Stage/Floor Show or Contests (Describe):
	d.)	If musical entertainment, what type?:
		Alternative	Classic Rock	Country
		Jazz	Rap	R&B
		Soft Rock	Top40's/Pop
		Other
	e.)	Is dancing permitted?		Yes No
	f.)	Is there a dance floor?		Yes No
		If yes, size of dance floor: Total Area of Premises:
12	Is there a Minimum or Cover Charge?			Yes No
13	Are Bouncers or Doorpersons employed? If yes, risk must be rated in category 1 or submitted to home office for exception.			Yes No
14	Are facilities available for Banquets, Receptions or Private Affairs?			Yes No
	a.)	If yes, how many functions are handled annually?
		Describe types:
	b.)	Are dancing and entertainment featured at banquet operations?		Yes No
15	Are all alcohol-serving employees certified in a FORMAL ALCOHOL TRAINING COURSE?			Yes No
	If yes, provide name of the course (i.e.; TIPS, TAM, RAMP, BEST, etc):
16	a.)	HOURS OF OPERATION; Mon-Thurs Fri
		Sat Sun.
	b.)	Does establishment ever stay open past 2 a.m.?		Yes No
		if yes, was the establishment required to apply for a special license?		Yes No
17		Are operations seasonal?		Yes No
		If yes, what is the season? to
18		Does applicant engage in off-premises sales or service of alcohol?		Yes No
		(If off-premises coverage is desired, attach a complete off-premises supplemental application, form LLA-OPS, to this submission)
19	Does applicant have any mechanical rides or devices (mechanical bull, virtual reality, etc)			Yes No
		If yes, total number and types:
20	Are guns permitted or kept on premises?			Yes No
21	Are employees permitted to consume alcohol on the Job?			Yes No
22	Does applicant have any drink specials or promotions (2-for 1's, happy hours, reduced drink prices, etc)?			Yes No
		If yes, describe type, days and times of specials:
23	Docs applicant offer complimentary drinks?			Yes No
		If yes, explain:
24	Does applicant permit "BYOB" (bring your own bottle) or setups?			Yes No
		If yes, explain:
25	Is establishment frequented by a college crowd?			Yes No
26	What is the average age of patrons?
27	If a bar or tavern, are persons under the legal drinking age permitted on premises?			Yes No
		If yes, explain:
28	Within the past 5 years, has applicant and/or employees of the applicant's establishment been fined or cited for violations of law or ordinance related to Illegal activities or the sale of alcohol?			Yes No
		If yes, provide date(s) and details of citation(s)
29	Within the past 5 years, has the applicant had any Liquor Liability Claims (whether insured or not)?			Yes No
		If yes, provide date(s) description of claim(s) and status:
30	Within the past 5 years, has the applicant had any Assault & Battery Claims?			Yes No
		If yes, provide date(s) description of claim(s) and status:
31	Within the past 5 years, has applicant's liquor coverage been Cancelled or Nonrenewed?			Yes No
		If yes, explain:
32	Previous Liquor Carrier:
		Limits Premium
33	Desired Policy Period: to
34	Limits Desired:		Each Common Cause Limit:
		Aggregate Limit:
35	Is an ADDITIONAL INSURED needed?			Yes No
		If yes. Name is:
		Address is:
		Describe Insurable Interest:
FRAUD STATEMENT: Any person who knowingly and with the 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 penally not to exceed five thousand dollars and the statcd value of the claim for each such violation.
WARRANTIES: I/we warrant that the information contained herein is true and that it shall be the basis of the policy of insurance and deemed incorporated therein, should the company evidence its acceptance of this application by issuance of a policy. I/we agree that such policy shall be null and void if such information is false, or misleading, or would materially affect acceptance of the risk by the company, I/we hereby authorize release of claim information from any insurers or their general agent. I/we warrant that premises liability coverage will be maintained at limits at least equal to the liquor liability limits during the entire term of the liquor policy. I/we agree to submit records for audit by the company upon termination or expiration of this policy for the determination of actual gross receipts during the period of coverage, if requested.
	Signature of Applicant* __________________________________________________________
		Title: required
		Date: required
	*SIGNING THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE COMPANY TO COMPLETE THE INSURANCE
	The State of New York requires that we have the name and address of your (Insured's) authorized agent or broker.
		Name of Authorized Agent or Broker:
		Address:
		Mail completed Application through local agent or broker to: