General Information
Organization Name and #:  
Contact Name:  
Address:  
City:  
State:  
Zip:  
Phone (Social Room):  
Phone (Office):  
Best Time To Call:

 
Fax #:  
Contact Email Address:     
Coverage Effective Date:  
Quote Needed By:  
Federal ID#:  
Current Insurance Information
Company Name (not agency):  
Policy Expiration Date:  
Premium Amount:  
Current General Liability Limits:  
Current Liquor Limits:  
What type of coverage do you currently have:
Own or Lease:  
Building value:  
Current Deductible:  
Year of Last Mechanical Update:  
Age of Building:  
Construction Type:  
Square Footage You Occupy:  
Miles From Fire Dept Hydrant:  
Contents Value:  
RC or ACV Coins:  
Property Form:  
Number of Stories:  
Total Square Footage:  
Miles From Coast:  
Basement?  
RV Spaces:  
How Many?  
About Your Facilities
Do you have restaurant kitchen facilities?  
Annual Food Sales:  
Deep Fryer:  
Broiler:  
Grill:  
Automatic Fire Suppression System for all
cooking surfaces:		  
Do you have a bar?  
Open to public:  
Annual Sales:  
Current Membership:  
Organization Information
How many times per year is your facility
rented, either for a fee or at no cost?		  
Are all renters required to sign a rental
release contract?		  
Does your rental agreement contain a
"hold harmless" cause in your favor?		  
Does rental agreement make the renter
responsible for security?		  
Rental Income:  
Does your organization engage in any
bunny/turkey shoots, fireworks displays,
carnivals, have any lakes or recreation
campgrounds, parades, ball fields or
swimming pools?:
  
If yes, which:






Does your organization offer bingo?  
Open to public:  
Is liquor sold during bingo?  
Annual income:  
Does your organization offer gaming?  
Open to public?
Is liquor sold during gaming?
Annual income:  
Does the aerie have any employees?
Annual Payrolls?  
Does the aerie have any autos?
If so, what:  
Does the applicant have a valid liquor
license?
Name and License #:  
Has the applicant or any principal with a
controlling interest in the applicant filed
for bankruptcy in the last 12 months?		  
Are employees or other persons permitted
to consume alcohol during their hours of
employment or service?		  
Are all alcohol-servers certified in a Formal
Alcohol Training Course not mandated by the
state?
  
If yes, provide name of the course:  
Violations: Does the applicant have knowledge
of any fines or citations for violation of of law
or ordinance related to illegal activites or the
sale of alcohol at this location within the past
five years?		  
*If yes, provide the following information on each fine or citation:
Date(s):  
Description(s):  
Measures in place to prevent future violations:  
Claims: Has the applicant had any reported
liquor liability and/or assault and battery
claims or notificaiton of potential liquor
liability and/or assault and battery claims
within the past five years?
  
Date(s)  
Description(s)  
Total incurred losses (reserves and payments):  
Status (open or closed):  
Measures in place to prevent future incidents:  
Does applicant permit "BYOB" (bring your own
bottle), bottle service or setups?		  
*If yes, explain:  
Does applicant feature any
entertainment:		  
*If yes, Major Entertainment
(check all that apply):





 
Number of times per week:  
Number of times per year:  
Miscellaneous Information
Describe any other losses in the last five years:  
Any other coverages: (Employee Dishonesty,
Money & Securities, Directors and Officers, etc.)		  
Additional Comments
Please give any additional comments you feel
appropriate for this quotation.  If you have
additional information where there was not
enough space, please enter them here:		  
How did you hear about us?
Please let us know how you found out about
our agency on the internet:




Submit Information
Click Submit and a representative from Jackson
and Jackson Insurance will contact you by:		  
Best time to call:  
Fax Number: