Nightclub Application (Short Form)
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Corporate Name:
Location Address:
City:
State:
Zip:
Trading Name:
Phone:
Website:
Number of Locations:
Number of years of management experience the General Manager/Owner has at this location or another location that is a similar establishment:
Does the applicant own the building/property?
Does the building have Apartments?
if Yes, # of Apartments:
Broker Information:
Proposed Effective Date: (mm/dd/yyyy)
Calendar
Proposed Expiration Date: (mm/dd/yyyy)
Calendar
General Liability (Please Select Desired Limits)
Requested Limit
Per Occurrence
General Aggregate
Products/Completed Operations
Personal/Advertising Injury
Assault and Battery
Employee Benefits
# of Employees:
Liquor Liability
Hired Auto & Non-Owned Auto
Square Footage:
Protection Class:
Capacity:
Is there cooking on premises?
If yes, is the cooking area, hood and duct system protected by a fire extinguishing system?
Does the applicant ever engage in 24 hour operations?
Does the applicant have a parking lot?
If yes, How many spaces?
Is parking lot used for special events?
Total Food Receipts
Total Alcohol Receipts
Total Door/Cover Receipts
Total Ticket Sales for Live Music Receipts
Total Banquet/Catering Receipts
Total Other (not listed above) Receipts
Total Expense Paid to Bands for Live Music
Total Expense for Comp Admissions
Total Gross Receipts
Does the applicant engage in facility or room rentals for private events?
Does the applicant have or plan to have during the policy period any of the following types of entertainment?
(select all that apply and indicate the frequency)
times per week:
times per week:
times per week:
times per week:
times per week:
times per week:
times per week:
Are patrons permitted to dance?
Does the applicant allow anyone to dance or stand on any raised equipment, including but not limited to, speakers, furniture, tables, chairs, or bar-top?


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