Hospitality Insurance Form - Hospitality Direct

Online Hospitality Insurance Application

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Confirmation

Name of Broker:

Partners Indemnity Insurance Brokers

*Applicant's Business Name:

Operating Name(s):

*Email Address:

Website Address:

Type of Entity:

Mailing Address:

Legal Address:

Establishment Type:

Describe other Operations:
(500 Characters Max.)

Operating Since:

Years of Experience in this Type of Business:

10.

Is this a Seasonal Operation? Yes No

If Yes Describe:

11.

Have you ever been assessed a fine for violation of a law concerning the sale of alcohol or had your liquor license suspended / revoked or any decisions or disciplinary action pending?
Yes No
If Yes, please provide # of days of suspensions/revocation and detailed description of violation/infraction:

12.

Financial Information:

Liquor/Wine/Spirits Receipts:	$	Name of Accountant:
Food Receipts:	$	Fiscal Year End:
Coverage Charge Receipts:	$	Payroll:
Other Receipts:	$	Details of Other:
Total Receipts:	$

*This resets the entire form and starts you from page 1.