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Insurance Questionnaire

Please take a moment to fill out the questionnaire below and one of our representatives will contact you with a free, no-obligation quote. This information will be kept confidential and will be used for quote purposes only.

* Required fields.

General Information
Corporate Name:
DBA Name:
Contact Name: *
Type of Establishment:

Club Address:
Club City:
Club County
Club State:	Club Zip:

Mailing Address: (if different)
City:
State:	Zip:

Club Phone:
Office Phone:
Cell Number:
Fax Number:
Alt. Number:
E-mail Address: *
Website Address:
Best Time to Call:

Property Information
Building Construction:
Year Built:
Roof Materials:
Year Roof Updated:
Year Wiring Updated:
Year Plumbing Updated:
Year Heating Updates:
Bldg. Square Footage:
How Many Floors:
Central Station Alarm:	Yes No
If Yes, Alarm Company:
Central Station FIRE Alarm:	Yes No
Fire Extinguishers:	Yes No How many:
Smoke Detectors:	Yes No How many:
Sprinkler Systems:	Yes No
Cooking:	Yes No
Ansul System:	Yes No
Number of Exits:	_
Building Value:	$
Contents Value:	$
BI w/EE Value:	$
TI&B Value:	$
Sign Value:	$
Awnings Value:	$
Other Value:	$

Sales Information
Annual Food Sales:	$
Annual Liquor Sales:	$
Annual Misc. Sales:	$
Type Misc Sales:	_

Misc Information
Own/Lease:	Own Lease
Years in Business:
Years Experience:
Dance Floor:	Yes No
If Yes, Sq Ft of Dance Floor:
Do You Have Live Entertainment?: (Karoke, DJ, Band):	Yes No
If Yes, what type & how often?: (Country, Top 40, Latin, etc.)
Dart Boards, Pool Tables, Video?:
Days of Operation:
Hours of Operation:
Happy Hour? Specials?	Yes No
TABC/Alcohol Board Certified	Yes No
Under 21 Allowed:	Yes No
Seating Capacity:
Claims	Yes No
If Yes, Describe Claims:

Prior Coverage Information
Current Insurance Agency:	_
Coverage Expiration Date:	_
Current General Liability Carrier:	_
Current General Liability Limits:	_
Current Liquor Liability Carrier:	_
Current Liquor Liability Limits:	_
Current Property Carrier:	_
Current Premium:	$
Renewal Premium:	$

Liability Information
Payroll:
No. Full Time Employees:
No. of Part Time Employees:

Please click the "Submit Responses " button to send your questionnaire responses. No coverage is in effect until bound by an insurance carrier. This is a request for quotation only.


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