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Complete the following information if you would like to obtain a Liquor Store Insurance quote. Please understand this is not an application. An application will be sent to you if coverage is desired.
All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information
What is your name?
What is your business name?
Business Name
What is your address?
What is your telephone number?
What is your fax number?
What is your email address?
Underwriting Information
How many owners?
Number of Owners
How many employees?
Number of Employees
What is the payroll amount of the owners?
Payroll of Owners
What is the payroll amount of the employees?
Payroll of Employees
What is the total annual gross?
Total Annual Gross Receipts
What are the total annual sub-costs?
Total Annual Sub-Costs
What is the business license number?
Business License Number
What is the license type?
License Type
Years of experience in this business?
Years of Experience
How many years have you operated under your current business name?
Years Operated Under Current Name
Have you used any other business names during the past 5 years?
Other Business Names
Yes No
Is this business open 24 hours a day
Open 24 Hours
Yes No
Any deep frying (food)?
Deep Frying
Yes No
Is there any manufacturing, mixing, re-labeling or repackaging of products?
Yes No
Is there filling of propane tanks?
Propane Tank Filling
Yes No
Please describe the nature of your business and ANY unusual exposures.
Unusual Exposures
Building & Property Information
What is the total square footage of the building your business is in?
Total Square Footage of Business Building
What is the total square footage of your business only?
Total Square Footage of Business Only
What is the square footage of the customer area only?
Square Footage of Customer Area
How many stories is it?
If it's two stories, what is the ground floor square footage?
Ground Floor Square Footage
What is the construction type?
Construction Type
What type roof covering?
Has the roof been updated?
Roof Updated
Yes No
If yes, what year?
Year Roof Updated
What is the distance of fire protection?

Is the business in a brush area?
Yes No
Do you have a storage area more than 1500 Sq. Ft.?
Storage Area
Yes No
Are there smoke detectors at this location?
Smoke Detectors
Yes No
Are there fire extinguishers?
Fire Extinguishers
Yes No
Are there deadbolts on all doors?
Yes No
Are there circuit breakers?
Circuit Breakers
Yes No
Is the electrical updated?
Electrical Update
Is the heating/ air conditioning thermostatically controlled?
Thermostatically Controlled
Yes No
Is the heating/ air conditioning central?
Yes No
Has the plumbing been updated?
Plumbing Updated
Yes No
If yes, what year was the plumbing updated?
Year Plumbing Update
Does the building have interior automatic fire sprinklers?
Automatic Fire Sprinklers
Yes No
Is there a theft alarm?
Theft Alarm
Yes No
Is there a fire alarm?
Fire Alarm
Yes No
Are there any restaurants in your building
Yes No
Are there any restaurants in the building next to your business?
Restaurants Next to Business
Yes No
Claims Information
Where there any losses or claims in the last 5 years?
Losses - Claims
Yes No
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
What is the current insurance company?
How much are you paying now?
Amount Current Coverage
What is the liability limit requested?
Liability Limit
What is the building limit requested?
Building Limit
What is the building deductible requested?
Building Deductible
What is the business personal property (contents) limit requested?
Business Personal Property
What is the contents deductible requested?
Contents Deductible
What is the loss of income requested?
Loss of Income Coverage
Are there any questions, comments or additional coverage required?
Questions, Comments or Additional Coverage
Best Time to Contact You
Please let us know the best time to call and discuss your quote.
Or specify other:

Phone 334-687-0358 or 888-882-2181
Fax 334-687-2365
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