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Liquor Liability Application | Monoline

Please answer all questions completely. Completion of this application does not constitute coverage.

Liquor Liability Application | Monoline

Agency Information

Agency/Broker Name(Required)

Agency/Broker Code

Conifer, White Pine or Sycamore Code

Untitled(Required)

Email(Required)

Phone

Applicant Information

Business Name(Required)

Name on Liquor License(Required)

Business Address

Street Address Address Line 2 City State ZIP Code

Policy Effective Date

MM slash DD slash YYYY

Underwriting Information

Monoline Liquor Liability is available in Michigan and Illinois only. Terms may be available in other states with the accompanying General Liability

Alcohol Sales(Required)

Food Sales(Required)

Entertainment on Premises?(Required)

Yes

No

Which Days per Week

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Requested Liquor Liability Limit(s)(Required)

$50,000 occurrence / $50,000 aggregate

$50,000 occurrence / $100,000 aggregate

$100,000 occurrence / $100,000 aggregate

$100,000 occurrence / $300,000 aggregate

$300,000 occurrence / $300,000 aggregate

$300,000 occurrence / $600,000 aggregate

$500,000 occurrence / $500,000 aggregate

$500,000 occurrence / $1,000,000 aggregate

$1,000,000 occurrence / $1,000,000 aggregate

Is your client a member of one of our partner associations?

MIRA - Midwest Independent Retailers Association

Member #

Members may be eligible for premium discounts

Additional Information

Optional Attachments

Drop files here or

Accepted file types: pdf, docx, xlxs, Max. file size: 4 MB.

Example: Current policy, loss runs or underwriting information

Liquor Liability Application | Monoline

Liquor Liability Application | Monoline

Agency Information

Applicant Information

Underwriting Information

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