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Liquor Liability Quote

Agency Information:
Agent Name:
Note: This is the name of the agent requesting the quote, NOT the agency name.
Agency Name:
Agency Phone:  -  - 
Agency Fax (optional):  -  - 

Applicant Information:
Applicant Name:
Choose a state:
Number of years in business:
Number of years experience in this field:
Does the applicant have a valid liquor license:  

Basic Quote Information:
What is the desired effective date?
Type of risk:
Desired Limits:
What is the latest time the establishment will EVER close: 24-hour
Have all alcohol-serving employees taken an alcohol training course:  
Number of violations, losses or claims:
Has the applicant filed for bankruptcy in the last 12 months:  
Are employees allowed to consume alcoholic beverages while working:  
Are GL limits greater than or equal to liquor liability limits:  
Number of additional insureds needed:
Gross Alcohol Receipts: $
Gross Food Receipts:
Note: Only needed for restaurants

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This program is only available to properly licensed retail insurance offices
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