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  Liquor Liability Insurance Quote
Name of Business: 
Contact Name:
Street Address:  
City, State & Zip:  
Location Address:
(if different from above) 
City, State & Zip:  
Business Phone:
Contact E-Mail Address:
Website Address:
Fax:  
*Please email or fax copies of current policies, declarations, 3 year loss runs, and any other available information.
 
 Current Insurance Information
Insurance Company Name:
(NOT Insurance Agency/Broker)
Premium Amount:      Policy Expiration Date:
 
 Business Information
How long at this location: Years Months
How long in business:   years
Name on license:
Expiration date of license:

Describe your operation:
(i.e... private club, gas station, tavern or bar with nightclub entertainment, etc)

Annual liquor sales:
Percentage beer: %          Percentage wine: %  
Percentage all other alcohol: %    *Note: This should add to 100%
 
 Any additional comments or information that might be helpful in your quote:

No coverage of any kind is bound or implied by submitting information via this online form

Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.

We will not distribute information to other parties other than for insurance underwriting purposes.

By checking the box below you agree to release us from any liability should this information be accidentally viewed by others.

 

YES! I Agree - By checking this box, you agree to release us from any liability should this information be accidentally viewed by others and you specifically agree that you are permitting any records to be run and reviewed in order to provide you with the best quotation including but not limited to accident loss history, motor vehicle record and credit.

 

   
 

 

 

(p) (828) 258-8030 ∙ (f) (828) 258-8030
(e) tony_johnson_agency@nationwide.com