Free Response in Opposition to Motion - District Court of Arizona - Arizona

Case 2:O3—cv—OOO53—SI\/II\/I D0cument227—17 FiIed10/20/2006 Page10f3

CENTURY SURETY GROUP \/
LIQUOR LIABILITY APPLICATION
(Complete a Separate Application for each location)
1. Name of Applicanttinclude dba):
2. Mailing Address:
3. Location Address:
4. Applicant is: El Individual ij Partnership El Corporation ij LDC lj Other
Ifother, explain:
5. Location is: El Bar or Tavem lj Caterer El Country Club D Mini Mart without Gas
lj Mini Mart with Gas ij Motel/Hotel El Package Store lj Private Club
ij Restaurant El Special Event (short term) ij Sports Bar
EI Supermarket or Grocery Store El Other (explain):
(Note: lf more than one of the above applies at this location then “x" each applicable box)
6. lf private club, indicate type (be specific) and purpose:
7, Type(s) of Liquor License? lj On Sale El Off Sale
Cl Beer El Wine El Liquor
8. Show Hours and Days of Operation: Monday Tuesday Wednesday
Thursday Friday Saturday Sunday
9. Show Receipts:
a. Alcoholic Beverages
b. Food ._____________ ____;_________
c. Other ___________
10. Indicate type of area where you are located: D Commercial (Non—Industrial) El Downtown EI Industrial
El Residential El Resort El Rural El Suburban
1 1. Do you have any ofthe following? lj Athletic Contests or Events El Bouncers El Comedy Shows
El Dance Floor ij Dart Board El Disc Jockey lj Doomran
El Exotic Dancers El ID Checkers El Live Music El Mechanical Rides
lj Movies or Videos El Pinball Machines D Pool Tables El Shufiieboard
El Security Guards (employees) El Video Games lj Nude Dancers or Nude Reviews
D Security Guards"‘(independent) El Firearms on premises
*Do independent contractors carry liability insurance and provide certificates? El Yes El No
If you x’d any of` above boxes, explain in detail (be specitic about type of music provided, etc.):
Night Clubs (or any risk where entertainment is a primary function) is only written on a claims made form.
12. Do you sponsor or provide an of the following? El Double for single prices El Free Alcoholic Drinks
El Ladies Night LX.] 2 for 1 drinks D Singles Night El Drink Specials
13. Percent of` patrons arriving and departing by automobile? %
14. Maximum number of employees (including owners and managers) on duty at any one time?
15. Maximum capacity of premises allowed by law?
16. Maximum number of patrons on premises at any one time?
17. Average number ofpatrons on premises at any one time?
18. Predominate age range of` patrons? El 21 - 35 El 26 - 35 ij Over 35
19. Do you allow anyone under 21 on your premises? lj Yes lj No
lf yes, explain
20a. Have ou or this establishment ever been charged, cited or fined by ABC commission or other governmental regulator?
lj Yes El No lfyes, explain
20b. Have you or this establishment ever had its alcohol beverage license suspended or revoked? U Yes D No
20c. Number of bartenders? Number ol`other employees serving alcoholic beverages?
CSL-70l 1 (01/98) Page l of`2
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CENTURY SURETY GROUP
20d. Does this establishment have an alcohol awareness training program for the prevention ofalcohol abuse?
El Yes El No Ifyes, complete the following:
Yes No
1. Are all sewers trained within sixty (60) days of employment'? Ei El
2. Do you provide written policies and procedures to employees regarding minimum service
to minors and intoxicated persons? El lj
3. Name of awareness program:
4. Do you provide free rides home to intoxicated patrons? El El
lf yes, explain:

.
21. Prior Insurance/Loss History:
Show li uor liabilit insurer s for ast three 3 ears:
Year Insurance Com an Polic Number
Have you had any liquor liability claims (insured or uninsured) in the past three (3) years? I Yes I No
If es, list them below:
Year Descri tion of Loss Amount Paid or Reserved
22. Show insurer, policy term and limits for general liability coverage (limits must equal or be greater than the liquor liability
limits)
23. Was your last liability coverage on a claims made coverage form? lj Yes El No ls this application for claims
made form? El Yes lj No Ifyes, is Prior Acts Coverage desired? lj Yes lj No If yes, attach a copy of
current declarations page showing retroactive date.
24. Do you have knowledge of any injury or accident which might have been caused by the serving of alcoholic beverages
from your establishment which occurred after the requested effective date and prior to the completion of this
application? El Yes lj No lf yes, explain in detail including name of injured party and date of incident:

Requested limits (in thousands) E 100/100 El 100/300 lj 300/300 lj 500/500 ij Other
Requested *Deductible El $500 El $1,000 El $2,500 El $5,000
*Deductible applies per claim including defense expense for claims.
Requested policy term: to Contact Person: Telephone #
The Claims Made Liquor Liability form only provides coverage for "injury" which occurs after the
retroactive date (and which you had no knowledge of prior to the effective date of this policy) shown in
the policy (see #23 of this application) and reported (in writing) to the insurance company during the
coverage period of this policy and I fully understand this limitation.
I declare that the above statements and particulars are true and that no fact have been suppressed or misstated and that this
application form is recognized to be the basis of any policy of insurance which may be issued by the Company. The
completion of this application does not bind the company to sell, and the misstatements of facts may void your coverage.
Any person who, with intent to defraud or knowirg that he is facilitating a fraud against an insurer, submits an application
or tiles a claim containing a false or deceptive statement is guilty of insurance fraud.
Applicant: Producer:
Signature:
Date: Producer Signature:
CSL-7011 (01/98) Page Z oi'2
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