subject_line
Package Store Insurance Questionnaire
First Name:
*
Last Name:
*
Email Address:
*
Web Address:
*
Company Phone:
*
Named Insured (Legal Business Name):
*
FEIN#:
Type of Business:
*
Retail Package Store
Wholesale Liquor/Wine Distributor
Year Business Started:
*
Location Address:
*
City:
*
State:
*
Zip:
*
Mailing Address (If different from Location Address:
City:
State:
Zip:
Business Owner's Policy Information
Square Footage Leased:
*
Year Building Systems Were Updated: (If No Updates, enter N/A in the field)
Year Updated:
Roof:
Year Updated:
Electric:
Year Updated:
Plumbing:
Year Updated:
Heating:
Year Updated:
Building Limit of Coverage:
Contact/Stock of Coverage:
*
Annual Sales (Revenue):
*
Online Sales (Revenue):
*
Operations Open 24 hours a day?
*
Yes
No
Offer Delivery Service?
*
Yes
No
Have employees received TIPS training or other alcohol training programs?
*
Yes
No
Has there ever been a citation issued by an Alcohol Beverage Commission?
*
Yes
No
Current Insurance Company:
*
Renewal Date:
Premium:
Any Property or Liability Claim in the last three years?
*
Yes
No
If yes, please explain:
Does the store have any of the following:
Security Camera
Fire Alarm
Burglar Alarm
Fire Sprinkler System