LIQUOR STORE WORKSHEET

First Name: Last Name: Business Name: Address: City: State: California Zip Code: Phone Number: Fax Number: eMail Address:    UNDERWRITING INFORMATION   Number of Owners:   Number of Employees: (or Enter NONE) Payroll of Owners: Payroll of Employees: (or Enter NONE) Total Annual Gross Receipts: Total Annual Sub Costs: Business License Number: License Type: Years of Experience: (or Enter NONE) How many years have you operated under your current Business Name? Have you use any other Business Names during the past 5 years? Yes  No Is This Business Open 24 Hours A Day? Yes  No Any Deep Frying (Food)? Yes  No Is There Any Manufacturing, Mixing, Re-Labeling or Repackaging of Products? Yes  No Is there Filing Of Propane Tanks? Yes  No Please Describe the Nature of Your Business and ANY Unusual Exposures:    BUILDING & PROPERTY INFORMATION   Total Square Footage of the Building Your Business Is In:   Total Square Footage of Your Business Only: (or Enter SAME) Square Footage of the Customer Area Only: How Many Stories: 1 2  If Two Stories, Ground Floor Square Footage:   Construction Type: Frame Masonry Veneer Masonry Superior   Roof Type: Tile Slate Metal Woodshake Composite Material   Roof Updated? Yes  No  If Yes, Year Roof was Updated: Protection Distance: 1000 ft or less to a hydrant & 5 mi or less to a fire station Over 1000 ft to a hydrant & 5 mi or less to a fire station Over 5 & up to 10 mi to a fire station Over 10 mi to a fire station  Is the Business in a Brush Area? Yes  No  Is there Storage more than 1500 Sq Ft? Yes  No  Are there Smoke Detectors at this Location? Yes  No  Fire Extinguisher? Yes  No  Deadbolts on All Doors? Yes  No  Circuit Breakers? Yes  No  Electrical Updated? Yes  No  Heating - Air Conditioning, Thermostatically Controlled?: Yes  No  Heating - Air Conditioning, Central? Yes  No  Plumbing Updated? Yes  No  If Yes, Year Plumbing was Updated: Interior Automatic Fire Sprinklers:  None Partial Full  Theft Alarm: None Local Central  Fire Alarm: None Local  Any Restaurants in your Building? Yes  No  Any Restaurants in your Building "Next to Your Business"?  Yes  No   CLAIMS INFORMATION   Losses-Claims in the last 5 years:    none one two three four five   If yes, Date, Amount Paid and Description of Each Loss-Claim:    COVERAGE INFORMATION   Current Insurance Company:   How much are You Paying Now?: Liability Limit Requested: $100,000 $300,000  $500,000 $1,000,000  Building Limit Requested: Building Deductible Requested: $250 $500  $1,000 $2,500  Business Personal Property (Contents) Limit Requested: Contents Deductible Requested: $250 $500  $1,000 $2,500  Loss Of Income Limit Requested: Questions or Comments or Additional Coverage you may need: Please press the Submit Button ONCE. Then wait for online confirmation of your request. Thank you for your interest.