1. What is the average amount of money kept on premisis during normal operating hours?
2. What is the average amount of money carried off premisis?

1. What is replacement cost of computer hardware?
Software

How long has business been in operation?
How long under current management?
How many employees?
Has application ever been cited for violation of beverage laws? Yes No
Has applicant ever been sued? Yes No

Describe all losses over $10,000 in the last five years.

Name of current insurance company and expriation date of current policy.
Name Exp. Date

Please describe the equipment you have for your operations & value.

What is the maximum value in any one cooler at any one time?
Is coolant ammonia? Yes No

What persentage of production does macheriny effect? %

Are there any painted panes? Yes No

Are panes fixed, glued or in angle settings? Yes No

Any obstructions or unusual settings? Yes No

Is any glass structural? Yes No

Is the building under construction? Yes No

Does any of the glass have any defects, cracks or scratches? Yes No

Are any locations with glass vacant? Yes No

1. Are employees required to wear protective gear in bottling areas?
   Yes No
2. Do you wish to purchase product recall coverage limit?
   (coverage is available and reviewed by company of written recall plan)
   Yes No If yes, limits desired $25,000 $50,000
   
   
3. How are solid wastes disposed of?
   
4. Is there a contract in place for waste disposal? Yes No
5. Spoilage Limits desired: $10,000 $25,000 $50,000
6. Do you have an open line of credit with a financial institution for your business? Yes No If yes, what is your limit? $
7. Do you sponsor or promote any special events or activities off premises?
   Yes No
   If Yes, please provide a brief descriotion of those activities.
   

How many Employees? Annual Payroll

Are tours of your facility being conducted?	Yes No
Procedures in place to prevent patrons from coming in contact with hazards?	Yes No
Do you provide a hospitality room for patrons to sample your product?	Yes No
Do you sell beer to patrons for on-premises consumption? (brewpub operation)	Yes No
Are you currently involved with any contract brewing?	Yes No
If yes, give details of contract:

Brew Pubs Only

Are controls in place to avoid serving liquor to minors and persons who are intoxicated?	Yes No
To what extent do the servers of alcholic beverages participate in programs such as TIPS training?
Is there a system in place to provide intoxicated persons transportation home?	Yes No
Are ID's checked at the door, especially during busy hours of operation?	Yes No
Liquor License Holder:
Liquor License Number:
Has license ever been revoked, suspended or fined?	Yes No
Is entertainment provided?	Yes No
Other coverages desired:(please check) Umbrella Worker's Comp Auto Employee Benefits Inland Marine Special Events Liability
Please note: This is only an application for insurance coverage; no coverage has been extended or bound. The intent is not to describe or outline coverages. Coverages are sbuject to the terms, conditions and exclusions contained in an actual policy of insurance. You should consult your actual policy for a complete description and details regarding coverage, conditions to coverage and exclusions to coverage.