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Convenience Store Supplement - Liquor


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Company Information
Company Name *
First Name *
Last Name *
Street *
City *
State *
ZIP / Postal Code *
E-Mail Address *
Primary Phone Number *
Additional Information
Liquor License Number:
Are there any ATMs on the premises?

Are there any Lottery Machines on the premises?

If you have ATMs or Lottery Machines, plesae list receipts:
LPG Sales:

LPG Filling:

LPG Tank Swap:

Are there any firearms on the premises?

Ansul System:

If you have an Ansul System, what is the frequency of service?
Hoods/Ducts:

If you have Hoods/Ducts, what is the frequency of service?
Previous Liquor Liability Carrier:
Policy Number:
Claims in past 5 years:
Describe the claim/amount of claim:
Have you been cancelled?

If yes, please list the reason:
Liquor License Held:

Type of license:

Is there any cooking on the premises?

Type of cooking:



Is there a burglar alarm on the premises?

Is there a fire alarm on the premises?

If yes, please enter the name of the Alarm Company:
Panic Button(s):

Average amount of cash:
Maximum amount of cash/checks on the premises:
Is there a video camera?

Are there Security Guards on the premises?

If yes, how many are armed?
How many are unarmed?
Is there a time lock safe on the premises?

Time Intervals:
Who is responsible for the deposits?
What is the frequency of deposits?
Number of self service pumps:
Number of full service pumps:
Any auto repair?

If yes, please describe:
Submission Validation
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Judy Carter & Associates   300 Vestavia Parkway   Suite 1600   Birmingham, Alabama 35216