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Convenience Store Supplement - Liquor


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Company Information
Company Name
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First Name
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Last Name
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Street
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City
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State
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ZIP / Postal Code
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E-Mail Address
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Primary Phone Number
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Additional Information
Liquor License Number:
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Are there any ATMs on the premises?
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Are there any Lottery Machines on the premises?
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If you have ATMs or Lottery Machines, plesae list receipts:
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LPG Sales:
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LPG Filling:
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LPG Tank Swap:
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Are there any firearms on the premises?
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Ansul System:
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If you have an Ansul System, what is the frequency of service?
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Hoods/Ducts:
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If you have Hoods/Ducts, what is the frequency of service?
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Previous Liquor Liability Carrier:
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Policy Number:
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Claims in past 5 years:
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Describe the claim/amount of claim:
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Have you been cancelled?
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If yes, please list the reason:
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Liquor License Held:
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Type of license:
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Is there any cooking on the premises?
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Type of cooking:
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Is there a burglar alarm on the premises?
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Is there a fire alarm on the premises?
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If yes, please enter the name of the Alarm Company:
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Panic Button(s):
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Average amount of cash:
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Maximum amount of cash/checks on the premises:
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Is there a video camera?
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Are there Security Guards on the premises?
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If yes, how many are armed?
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How many are unarmed?
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Is there a time lock safe on the premises?
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Time Intervals:
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Who is responsible for the deposits?
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What is the frequency of deposits?
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Number of self service pumps:
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Number of full service pumps:
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Any auto repair?
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If yes, please describe:
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Submission Validation
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Judy Carter & Associates   300 Vestavia Parkway   Suite 1600   Birmingham, Alabama 35216