September 2010, Volume 45
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Category: Eating and Drinking Places Risk: Bars

GENERAL CLIENT INFORMATION

Account: ___________________________________________________________

Account Number: ____________________________________________________

Agency: ____________________________________________________________

Agency Number: _____________________________________________________

Producer: __________________________________________________________

Producer Number: ___________________________________________________

BUSINESS LEGAL NAME MAILING ADDRESS

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Legal Entity:

___ Individual 

___ Corporation 

___ Partnership 

___ Joint Venture 

___ Sub-S Corp. 

___ Not for profit 

___ Limited Liability 



SIC CODE(s) ___________________________________

FEDERAL ID NUMBER ____________________________

YEARS IN BUSINESS ___________________________

Number of years under present management: ___ years

Number of years experience of owner: ___ years

Number of years experience of manager: ___ years

Has the risk ever been involved in a bankruptcy procedure? ___ Yes ___ No

If yes, explain: _____________________________________________________

Names of subsidiary companies or joint ventures that are not part of this application:___________________________________________________

__________________________________________________________________

IMPORTANT PEOPLE 

NAME OF YOUR CONTACT 

PHONE NUMBER 

OWNER/PRINCIPAL 

____________________________ 

______________ 

OTHER DECISION MAKERS 

____________________________ 

______________ 

PLANT AND GROUNDS 

____________________________ 

______________ 

FINANCIAL 

____________________________ 

______________ 

LEGAL 

____________________________ 

______________ 

CLAIMS 

____________________________ 

______________ 

The applicant’s primary operations are:______________________________________

_____________________________________________________________________

_____________________________________________________________________

The applicant’s secondary and incidental operations are:________________________

_____________________________________________________________________

_____________________________________________________________________

The applicant used to be involved in the following operations but they have been discontinued:

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

The hours of operation are: _____________________________________________

Number of days the business is open per week: _______________

Is this a seasonal operation? ___ Yes ___ No

What is the season? From _____________ To _____________

Does the applicant have a safety program? ___Yes ___No 

Name of safety director: ____________________________________________

Phone number of safety director:_________________________________

Attach copy of safety program.

Does the applicant have a disaster plan?_______

Name of disaster coordinator:_________________________________

Phone number of disaster coordinator:________________________

Attach a copy of the disaster plan. 

Clientele Age: ___ 18-25 ___ 25-35 ___ 35-50 ___ Over 50 Years 

Clientele Origin: ___ Families ___ Business/Professional
___ Students ___ Military ___ Other ________ 

Remarks: 

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Does the establishment specialize in certain foods or drinks? ___ Yes ___ No 

If yes, explain: ________________________________________________ 

Does the establishment draw its customers primarily from the immediate area? ___ Yes ___ No 

If yes, explain: ________________________________________________ 

Is the establishment located in a shopping center? ___ Yes ___ No 

What are the gross sales for past 3 years? _________________ 

20 ____ Food $ _______________ Liquor $ _______________ 

20 ____ Food $ _______________ Liquor $ _______________ 

20 ____ Food $ _______________ Liquor $ _______________ 

Are there operations away from the premises such as catering? ___ Yes ___ No 

If yes, explain: ________________________________________________ 

Live Bands? 

___ Yes 

___ No 

Days Per Week _____ 

Dance Floor? 

___ Yes 

___ No 

Days Per Week _____ 

Dancers? 

___ Yes 

___ No 

Days Per Week _____ 

Bouncers? 

___ Yes 

___ No 

Days Per Week _____ 

Female Reviews? 

___ Yes 

___ No 

Days Per Week _____ 

Male Reviews? 

___ Yes 

___ No 

Days Per Week _____ 

Disc Jockey? 

___ Yes 

___ No 

Days Per Week _____ 

Pool Tables? 

___ Yes 

___ No 

Days Per Week _____ 

Happy Hour activities? ___ Yes ___ No 

If yes, explain: _______________________________________________ 

Does the establishment use radio or television antennas (including satellite dishes) to receive programs to attract and entertain customers? ___ Yes ___ No 

If yes, explain: ______________________________________________ 

Other types of entertainment? ___ Yes ___ No 

If yes, explain: _______________________________________________