Nightclub Quote Form

Personal Information
First Name Required Input Required
Last Name Required Input Required
Corporation Name Required Corporation Name is required.
Street Required Input Required
City Required Input Required
State Required Input Required	select AL AK AZ AR CA CO CT DE FL GA HI ID IA IL IN KS KY LA ME MD MA MI MN MS MO MT NC ND NE NV NH NJ NM NY OH OK OR PA RI SC SD TN TX UT VT VA WA DC WV WI WY
ZIP / Postal Code Required Input Required Please enter a valid Postal code.
Primary Phone Number Required Input Required Please enter a valid phone number
E-Mail Address Required You must provide an e-mail address. A valid e-mail address is required.
Does the applicant own the building/property? Required Does the applicant own the building/property? is required.	select Yes No
Requested Limits for Assault and Battery: Required Requested Limits for Assault and Battery: is required.
Number of Employees? Required Number of Employees? is required.	select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200
Requested Limits for Liquor Liability Required Requested Limits for Liquor Liability is required.
Is there cooking on premises? Required Is there cooking on premises? is required.	select Yes No
Does the applicant ever engage in 24 hour operations? Required Does the applicant ever engage in 24 hour operations? is required.	select Yes No
Does the applicant have a parking lot? Required Undefined	select Yes No
If yes, how many spaces? Required If yes, how many spaces? is required.
Total Food Receipts: $ Required Total Food Receipts: is required.
Total Alcohol Receipts: $ Required Total Alcohol Receipts: $ is required.
Total Door/Cover Receipts: $ Required Total Door/Cover Receipts: $ is required.
Total Ticket Sales for Live Music Receipts: $ Required Total Ticket Sales for Live Music Receipts: $ is required.
Total Gross Receipts: $ Required Total Gross Receipts: $ is required.
Does the applicant have or plan to have during the policy priod any of the following types of entertainment?
DJ (times per week) Required DJ (times per week) is required.
Adult/Exotic Dancers (times per week) Required Adult/Exotic Dancers (times per week) is required.
Boxing/Ultimate Fighting/Touch Man Events (times per week) Required Boxing/Ultimate Fighting/Touch Man Events (times per week) is required.
Comedy Acts (times per week) Required Comedy Acts (times per week) is required.
National Touring Acts/Bands (times per week) Required National Touring Acts/Bands (times per week) is required.
Karaoke (times per week) Required Karaoke (times per week) is required.
Local Acts/Bands (times per week) Required Local Acts/Bands (times per week) is required.
Does the applicant have a dance floor? Required Does the applicant have a dance floor? is required.	select Yes No
Does the applicant have or plan to have during the policy period any of the following entertainment devices on premises? Required Undefined	Video Games Pool Tables Dart Boards TV's Other
Does or will the applicant ever allow persons other than employees trained in a formal alcohol awareness program to serve alcohol to patrons (e.g. other patrons, guest bar tender, etc)? Required Does or will the applicant ever allow perons other than employees trained in a formal alcohol awareness program to serve alcohol to patrons (e.g. other patrons, guest bar tender, etc)? is required.	select Yes No
Does or will the applicant engage in any type of underage promotions during the policy period including, but not limited to "teen", "under 21", or "18 and over" nights? Required Does or will the applicantengage in any type of underage promotions during the policy period including, but not limited to "teen", "under 21", or "18 and over" nights? is required.	Under 18 Over 18 Neither
Are firearms kept or permitted on premises? Required Are firearms kept or permitted on premises? is required.	select Yes No
Does the applicant have security, bouncers and/or door people? Required Does the applicant have security, bouncers and/or door people? is required.	select Yes No
What is the average number of security personnel on any given night? Required What is the average number of security personnel on any given night? is required.
Enter Validation Code Required

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