ACE Members

General Information

ACE Member Name *

Proposed Effective Date (mm/dd/yyyy)

Corporate Name *

ACE Member Number *

Proposed Expiration Date (mm/dd/yyyy)

Trading Name (DBA) *

FEIN (00-0000000) *

Mailing Address *

Number of Locations

City

State

Zip

Phone Number

Insurance Contact Email

Website

Different Primary Location Address?

Yes

Primary Location Mailing Address

Primary Location City

Primary Location State

Primary Location ZIP

Inspection Contact Name

Inspection Contact Phone

Inspection Contact Email

Business Formation Year (YYYY) *

Is the Member a sole proprietorship?

Yes

No

Has the Member or any active partner filed for bankruptcy?

Yes

No

Has the Member or any owner or principal ever been convicted of a felony?

Yes

No

Number of years of management experience the General Manager/Owner has at this location or another location that is a similar establishment:

Does the Member own all of the building(s)/property(ies)?

Yes

No

% of Building(s) Occupied by Member

Does the building have any commercial tenants?

Yes

No

% of Building(s) Vacant

Please list all commercial tenants & provide a detailed description of operations for each

Do all commercial tenants provide certificates of insurance evidencing equal limits and naming the Member and their entities as additional insured?

Yes

No

Does any buildings have apartments?

Yes

No

Number of apartments

Prior Coverage Information

New Venture

Coverage	Year (dd/mm/yyyy)	Prior Carrier	Prior Premiums
Liability	Liability Year *	Liability Prior Carrier	Liability Prior Premiums
Liquor	Liquor Year *	Liquor Prior Carrier	Liquor Prior Premiums
Excess	Excess Year *	Excess Prior Carrier	Excess Prior Premiums

Please Select the Coverages Desired

General Liability

$1MM Per Occurrence / $2MM Aggregate

Liquor Liability

$1MM Per Occurrence / $1MM Aggregate

$1MM Occurrence / $2MM Aggregate

Products and Completed Operations

$1MM Per Occurrence / $1MM Aggregate

$1MM Occurrence / $2MM Aggregate

Assault and Battery

$100K

$250K

$500K

$1M

Employee Benefits

N/A

$1MM

Emplee Benefits Retro Date

Retro Date (if applicable)Retro Date (if applicable)

Hired Auto and Non-Owned Auto Liability

Yes

No

Do you want to increase Damage To Rented Premises Limit?

$50K (Included)

$100K

$300K

$500K

Excess Liability Coverage

Operational Survey (All Locations)

Is there cooking on any premises?

Yes

No

Are the cooking areas, hoods and duct systems protected by a fire extinguishing system?

Yes

No

Is there any table side cooking?

Yes

No

Has the Member(s) ever been cited by the Board of Health?

Yes

No

Hours of Operations

Day of week	Open	Close
Monday	Monday Open	Modany Close
Thursday	Tuesday Open	Tuesday Close
Wednesday	Wednesday Open	Wednesday Close
Thursday	Thursday Open	Thursday Close
Friday	Friday Open	Friday Close
Saturday	Saturday Open	Saturday Close
Sunday	Sunday Open	Sunday Close

Does the Member ever engage in 24 hour operations?

Yes

No

Parking Operations

Does the Member have a parking lot?

Yes

No

How many spaces?

Are parking lots used for special events?

Yes

No

Provide address of any off premise lots to be included (spaces should be included in total above)

Does the Member provide complimentary transportation either to or from their location(s)?

Yes

No

Provide explanation

Does the Member offer valet parking?

Yes

No

Is valet parking provided by Employees or a Third Party Contractor?

Employees

3rd Party Contractor

If provided by third party contractor, do they provide certificates of insurance evidencing Garagekeepers coverage with at least $100,000 per auto and $1,000,000 aggregate and naming the Member and their landlord entities as additional insured?

Yes

No

Receipts

Proposed Term

Proposed Total Food Receipts

Proposed Total Alcohol Receipts

Proposed Total Door/Cover Receipts

Proposed Total Gross Receipts

(For Proposed Term)

Expiring Term

Expiring Total Food Receipts

Expiring Total Alcohol Receipts

Expiring Total Door/Cover Receipts

Expiring Total Gross Receipts

(For Prior 12 Months)

Rental / Catering

Does the Member engage in facility or room rentals for private events?

Yes

No

Entertainment

Does the Member have or plan to have during the policy period any of the following types of entertainment? (select all that apply and indicate the frequency in times per week)

Entertainment type DJ (times per week)

DJDJ

Entertaiment type Boxing/Ultimate Fighting Tough Man Events (times per week)

Boxing/Ultimate Fighting Tough Man EventsBoxing/Ultimate Fighting Tough Man Events

Entertaiment type Local Acts/Bands (times per week)

Local Acts/BandsLocal Acts/Bands

Entertainment type National Touring Acts/Bands (times per week)

National Touring Acts/BandsNational Touring Acts/Bands

Are patrons permitted to dance?

Yes

No

Does the Member allow patrons to dance or stand on any raised equipment, including but not limited to, speakers, furniture, tables, chairs, or bar-top?

Yes

No

Does the Member ever have or plan to have any type of stunt activity on any premises? (Stunt activity includes but is not limited to any type of acrobatics, carnival acts such as flame or sword swallowing, etc)

Yes

No

Provide explanation

Does the Member ever allow open flames and/or incendiary devices on the premises?

Yes

No

Provide explanation

Does the Member have or plan to have during the policy period any of the following interactive amusement device or activity on premises? (select all that apply)

Does the Member operate the swimming pool, in compliance with all regulatory laws and guidelines?

Yes

No

Other Business Locations

Docks, Slips or Piers (on water)

Number of Slips

Dock, Slip or Pier Address

Office (if separate location)

Office Square footage

Office Address

Warehouse/Storage (if separate location)

Warehouse/Storage Square footage

Warehouse/Storage Address

Dwellings

Dwellings Address

Radio/TV Broadcasting Stations

Radio/TV Number

Radio/TV Address

Vacant Building

Vacant Building Square footage

Vacant Building Address

Vacant Land

Vacant Land per Acre

Vacant Land Address

Bathhouse or Bathing Pavilion

Bathhouse or Bathing Pavilion Number

Package Liquor Store

Package Liquor Store Address

Other Business Location

Other

Other Business Location Explanation

Operations

Does or will the Member ever allow persons other than employees trained in a properly accredited alcohol awareness program to serve alcohol to patrons (e.g., patrons, guest bartender, etc.)?

Yes

No

Provide explanation

Does the Member ever permit or sponsor alcohol consumption games (e.g., beer pong, flip cup, etc.) or permit the use of alcohol consumption enticing equipment (e.g., beer bongs, funnels, etc.)?

Yes

No

Provide explanation

Does or will Member engage in any type of alcohol promotions during the policy period?

Yes

No

Provide explanation

Does or will the Member offer Open Bars/All You can drink specials (other than during facility or private rentals)

Yes

No

Does or will the Member offer any drink prices reduced to $1.00 or less?

Yes

No

Does or will the Member adhere to all statutes and regulations regarding drink specials?

Yes

No

Does the Member ever permit “BYOB” on the insured location?

Yes

No

Does the Member ever have package alcohol sales for off-premises consumption?

Yes

No

What percent (%) of receipts are derived from off-premises sales?

Does or will the Member permit patrons who are over 18 but under 21 on the premises after 10:00 PM?

Yes

No

will the Member utilize Tyvek wristbands to distinguish between those of legal drinking age and those under the legal drinking age?

Yes

No

Does the Member ever permit employees or other persons serving alcohol to consume alcohol during their hours of employment or service?

Yes

No

Does the Member ever permit the service of alcohol after the established legal operating hours?

Yes

No

Are patrons ever allowed on premises one hour after the established legal alcohol service cut-off time?

Yes

No

Has the Member been fined or cited for violations of law or ordinances related to illegal activities or the sale of alcohol?

Yes

No

Are firearms kept or permitted on premises by anyone other than police officers?

Yes

No

Provide explanation

Does the Member have any person(s) whose primary role is security, bouncer, ID checker and/or door person?

Yes

No

Security person(s)

Employees

Contractors

Are background checks completed on all security employees?

Yes

No

How frequently are background checks updated?

Does the Member ever employ persons who have been charged, sued and/or convicted with any assault and/or battery allegations?

Yes

No

Provide explanation

Are employees whose primary role involves security related functions required to be licensed by the state?

Yes

No

Are all employees actively licensed?

Yes

No

Does the Member have a written agreement with these contractors?

Yes

No

Submit a copy for our review

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If provided by contractor, do they provide certificates of insurance evidencing EQUAL General Liability limits and naming the Member and their landlord entities as additional insured?

Yes

No

Does the Member have a written policy regarding the striking and/or assaulting of patrons that is signed by all employees?

Yes

No

Does the Member engage police officers for work in or about the insured location?

Yes

No

Fire Safety

Are there secondary means of egress for each floor having public access at all locations?

Yes

No

Are there functioning and operational fire extinguishers and smoke detectors in all common areas?

Yes

No

Is the building armed with a functioning and operational automatic sprinkler system?

Yes

No

Is there a central station fire alarm?

Yes

No

When is the last time electrical wiring was updated? (mm/dd/yyyy) *

Total Square Footage

Legal Capacity

Security

Please check the appropriate box(es) to indicate how the police officers are engaged and their services invoiced

Through Municipality

Through a Secondary Employment Company

As an Individual

Number of security per:

Number of security per Monday

MondayMonday

Number of security per Tuesday

TuesdayTuesday

Number of security per Wednesday

WednesdayWednesday

Number of security per Thursday

ThursdayThursday

Number of security per Friday

FridayFriday

Number of security per Saturday

SaturdaySaturday

Number of security per Sunday

SundaySunday

Additional Insured

Please list any other entities Member is requesting to be added as Additional Insured

Additional Insured

Mailing Address

Additional Insured

Mailing Address

Additional Insured

Mailing Address

Additional Insured

Mailing Address

FRAUD STATEMENT: Any person who knowingly and with the intent to defraud any insurance company or other person, files an application for insurance 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.

The Member hereby certifies, based upon reasonable and diligent investigation and to the best of the knowledge of the Member, its owners, officers, employees and representatives, that with respect to the insured operation(s) and location(s) for which this application is being submitted:

Preliminary Claims History

Have there been two or more claims in any single period?

Yes

No

Provide explanation

Have there been, at any time, any alcohol related claims?

Yes

No

Provide explanation

Have there been claims during any policy period exceeding $25,000 in value based upon either the accumulated reserve or paid settlement amount?

Yes

No

Provide explanation

WARRANT: THE UNDERSIGNED REPRESENTS AND WARRANTS, TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, BASED ON REASONABLE INQUIRY, THAT THE PARTICULARS AND STATEMENTS SET FORTH ON THIS APPLICATION ARE TRUE, CORRECT AND ENTIRELY COMPLETE, AND THERE ARE NO OTHER RISK FACTORS THAT HAVE NOT BEEN DISCLOSED HEREIN. IF ANY PARTICULARS OR STATEMENTS ARE MATERIALLY MISREPRESENTED OR MATERIAL INFORMATION HAS BEEN OMITTED INTENTIONALLY OR ACCIDENTALLY, SUCH MISREPRESENTATION OR OMISSION WILL VOID ANY ISSUED COVERAGES AND THE INSURANCE COMPANY WILL HAVE NO DUTY TO DEFEND ANY CLAIMS, PAY ANY DAMAGES, OR PAY SUMS OR PERFORM ACTS OR SERVICES. THE UNDERSIGNED AGREES AND ACKNOWLEDGES THAT THE PARTICULARS AND STATEMENTS SET FORTH HEREIN ARE MATERIAL TO THE ACCEPTANCE OF THE RISK ASSUMED BY THE INSURANCE COMPANY AND THAT THE INSURANCE COMPANY IS RELYING UPON THE TRUTH AND COMPLETENESS OF THE RISK FACTORS DISCLOSED HEREIN. IT IS AGREED BY THE UNDERSIGNED THAT THIS APPLICATION, INCLUDING ANY MATERIAL SUBMITTED HEREWITH, SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED, AND THIS APPLICATION SHALL BE ATTACHED TO AND BECOME A PART OF THE POLICY. IF THE INFORMATION IN THIS APPLICATION MATERIALLY CHANGES PRIOR TO THE EFFECTIVE DATE OF THE POLICY, THE MEMBER WILL NOTIFY THE UNDERWRITER IMMEDIATELY IN WRITING AND THE UNDERWRITER MAY MODIFY OR WITHDRAW ANY OUTSTANDING QUOTATION OR PROPOSAL.

Signature of Member (Must be Owner, Officer, or Partner)

Full Name *

Title *

Location Survey

Location DBA	Street, City, State, Zip	Square Footage	Building Coverage Amount (or N/A)	Contents Coverage Amount	Hours of Operation
Location DBA #1	Location Address #1	Location Square Footage #1	Location Building Coverage Amount #1	Location Content Coverage #1	Location Hours of operation #
Location DBA #2	Location Address #2	Location Square Footage #2	Location Building Coverage Amount #2	Location Contents Coverage Amount #2	Location Hours of Operation #2
Location DBA #3	Location Address #3	Location Square Footage #3	Location Building Coverage Amount #3	Location Contents Coverage Amount #3	Location Hours of Operation #3
Location DBA #4	Location Address #4	Location Square Footage #4	Location Building Coverage Amount #4	Location Conetnts Coverage Amount #4	Location Hours of Operation #4
Location DBA #5	Location Address #5	Location Square Footage #5	Location Builidng Coverage Amount #5	Location Contents Coverage Amount #5	Location Hours of Operation #5

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Email Address *

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Sweeten Your Insurance Program

General Information

Prior Coverage Information

Please Select the Coverages Desired

Excess Liability Coverage

Operational Survey (All Locations)

Hours of Operations

Parking Operations

Receipts

Proposed Term

Expiring Term

Rental / Catering

Entertainment

Other Business Locations

Operations

Fire Safety

Security

Additional Insured

Preliminary Claims History

Signature of Member (Must be Owner, Officer, or Partner)

Location Survey

Brokers

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