Nightclub Application

IF YOU ARE A VENDOR OR EXHIBITOR PLEASE DO NOT FILL THIS APPLICATION OUT
CLICK THIS LINK FOR VENDOR / EXHIBITOR COVERAGE

Client Information
Organization    
Corporation: Name & DBA:*   Federal Tax ID #:
Physical Address   Mailing Address
Address:(No PO Boxes)*   Address:(No PO Boxes)*
Suite, Floor, ect..:   Suite, Floor, ect..:
City*   City*
State Zipcode*   State Zipcode*
         
Contact   Other Information
First Name:*   Effective Date/Renewal Date:
Last Name:*   # of years in business:
Phone:*   *Annual Food Sales:
Fax*   *Annual Alcohol Sales:
Email:*   Annual Cover Sales:
Website:   Annual Misc. Sales:


Establishment Details
Physical Specifications   Operations
*Sq. Feet of Building:   Hours of Operation: From: To:
Number of Stories:  
M T W Th F Sat Sun
Basement? Yes No   Is there entertainment? Yes No
Adjacent Tenants: Yes No   What type & how often?
Building Construction Type and Age:   How many video games, pool tables, darts, etc?
Roof Construction Type and Age:   Dancing: Yes No
Updates-years:   If yes, Sq. feet of dance floor
Wiring:      
Roofing:   General Information  
Plumbing:  
Any policy declined or cancelled during the prior three years?
Yes No
Any bankruptcies, tax or credit liens against the applicant in the past five years?
Yes No
Is parking lot under insureds control? Yes No
If yes, square footage:
Is valet parking provided? Yes No
If yes, employees or service?
Has there been any incidents involving assault & battery in the past three years?
Yes No
Number of bartenders/servers?
Full time Part time
Do you have a formal written safety program? Yes No
Average age of clientelle?
What is the seating capacity?
When is Happy Hour? Ladies Night?
What type of Certified training for bartenders and servers?
Heating:  
Located within city limits? Yes No  
Distance to shoreline?  
Cooking: Yes or No Yes No  
If yes, ansul system:  
Covers: all foods? Yes No  
Deep Fat Fryers? Yes No  
Open Flames? Yes No  
Service Contract for Cleaning? Yes No  
Cleaning company name?  
Date last cleaned?  
How often?  
Auto fire extinguishing system? Yes No  
Security System: Yes No  
Name of Monitoring Co:  
How many fire extinguishers:  
Sprinklered? Yes No  
Distance from fire hydrant?  
Distance from Fire Station?  


Coverage
Liability Amount:
Liquor Liab:
Assault & Battery: Yes No
Non-owned/hired auto: Yes No
Building Amount:
Contents Amount:
Tenant Improvements:
Loss of Income:
Do you currently have insurance? Yes No
With Who?
Present Premium:
Policy #:
Loss Information (Prior 5 years; dates & amounts:
Loss Payee Info:
Additional Insured Info:


Applicant
How did you hear about CSI Insurance?
Preferred contact method
 Email - Phone - Fax
Applicant Signature:*
Applicant Title:*

FRAUD STATEMENT: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON, FILES AN APPLICATION FOR INSURANCE COMPANY 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 BE SUBJECT TO CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. WARRANTY STATEMENT: I HEARBY WARRANT AND CONFIRM THAT THE ABOVE INFORMATION, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT, AND FURTHER CERTIFY THAT I HAVE READ ALL OF THE QUESTIONS AND ANSWERS ON THIS APPLICATION.
I UNDERSTAND THIS APPLICATION IS A REQUIREMENT FOR COVERAGE, A PART OF THE CONTRACT AND EVIDENCE OF MY ACCEPTANCE OF THIS INSURANCE, AND ANY FALSIFICATION OR MISREPRESENTATION WILL BE DEEMED A BREACH OF CONTRACT, VOIDING ALL INSURANCE COVERAGE. IT IS UNDERSTOOD AND AGREED THAT THE COMPLETION OF THIS APPLICATION SHALL NOT BE BINDING EITHER TO THE PROPOSED INSURED OR THE CMPANY UNTIL ACCEPTED BY THE COMPANY OR THE COMPANIES IN WRITING.