DRINKING ESTABLISHMENT – ALL TYPES

Policy # or Quote / Date
Broker / Submitted by

1. Name of Applicant:

Legal status of Applicant
Partnership / Corporation
Joint Venture / Other
(Specify)

2. Name and birthdates of all owners

3. Owners’ experience

4. Year incorporated
5. / How many years have the same owners been in operation at the same location? / Years
6. Years of experience in this field? / Years

7. Type of clientele

8. The Applicant operates
Bar without show / musician / Bar with dancers / Bar with show / musician
Discotheque / Licensed restaurant / Resto-Bar
Tavern / Brasserie / Hotel with bar / Nightclub / Comedy / Cabaret
Pool room / Ball Room / Private Club
Other, specify
9. Does the Applicant offer one or more of the following activities?
Yes No / Dance floor
Yes No / Musician / music / singer / Number of nights per week:
Yes No / Video games / Video Poker / Number of machines:
Yes No / Pool tables / Number of tables:
Yes No / Cash dispensers / :
Number of dispensers:
Yes No / Swimming pool / sauna / spa
Yes No / Room rental
Yes No / Sport activities – Inside or outside
Yes No / Does the Applicant sponsor or finance any exterior activities?
Yes No / Other promotional offers, specify:
10. Breakdown of annual receipts:
Alcohol / $
Food / $
Caterer / $
Pool room / $
Video Poker / $
Other, specify: / $
Total receipts / $
11. / Does the Applicant rent part of this establishment for special occasions? / Yes No
12. / What security measures are taken by the Applicant?
13. / What supervision does the Applicant use at the door?
Free entrance / Doormen / Bouncers
Other, specify
14. / Maximum capacity allowed?
Inside / Patio / Terrace
Other, specify
15. / Has Insured ever had liquor permit revoked? / Yes No
16. / Has the Applicant been subject to violations, convictions or penalty in the past 5years from the Régie? / Yes No
17. / Has the Applicant ever been refused, restricted or cancelled by an insurer? / Yes No
If Yes, explain
18. Previous Insurer?
19. Amount of Premium? / $
20. / PREVIOUS CLAIMS –An answer must be indicated. (If none, state NONE).
Detail hereunder all liability claims during the past 5 years, whether paid or not
Date / Bodily injuries / Property damage / Amount paid or outstanding
$
$
$
21. Have owners ever been prosecuted under criminal laws? / Yes No

If Yes, join copy of record.

The Applicant confirms that all information and facts described above are true and exact and that nothing was omitted or falsified.

Signature of Applicant /

Date

Broker’s signature /

Date

245 Yorkland Blvd. Suite 310
Toronto, OntarioM2J 4W9
Tel.: 1-855-745-1010
Fax: (416) 925-7260 / 2550, Daniel Johnson Blvd, Office 420
Laval, QC H7T 2L1
Tel.: 1-855-745-2020
Fax (450) 681-7313 / #100 1400 1st Street SW 4405, Lapiniere Blvd(head office)
Calgary, AB T2R 0V8 Brossard QC J4Z 3T5
Tel.: 1-855-745-1010 Tel: 1-855-745-1010
Fax: (403) 237-9976 Fax: (450) 672-5533