Name: Benson Insurance Group
Address: 5155 N. Academy Blvd., #110, Colorado Springs, CO, 80918, US
Telephone: (719) 622-3079

Agency Information
Agency Name:
Agency Code:
Producer Name:
Applicant Information
Full Name of Applicant (incl. DBA):
Mailing Address:
Street Address Address Line 2 City State ZIP Code
County:
Premises Address:
Street Address Address Line 2 City State ZIP Code
County:
Website Address:
Inspection Contact:
10 Digit Ph. No.:
Email
FEIN #:
Unemployment ID #:
Applicant Type:
- Owner
- Tenant
Entity Type:
- Club
- Corporation
- Individual
- Joint Venture
- Limited Liability Company
- Trust
- Other
Explain Other
Type of Operation:
- Banquet Hall
- Bowling Center
- Brewery, Craft Brewery, Microbrewery
- Caterer
- Convenience Store
- Distillery
- Distributor
- Fraternal Organization
- Franchise
- Gentlemen’s Club
- Nightclub
- Package Liquor Store
- Private Club
- Restaurant
- Tavern
- Other
Explain Other
Number of years in business at this location:
If less than 5 years, how many years as owner/manager of a similar type of business?
Please describe prior experience:
Policy Information
- Issue policy
- Quote Only
Lines to be Quoted:
- BOP
- Liquor Liability
- WC
- Umbrella
Inception Date:
Expiration Date:
Current carrier:
Target Premium ($):
Liability Section
General Liability Limit: ($)
Medical Payments Limit: ($)
Damage to Premises Rented to You Limit: ($)
Broadened Damage to Premises Rented to You Limit: ($)
Employee Benefits Liability Limit: ($)
Food Receipts: ($)
Liquor Receipts: ($)
Other Receipts: ($)
Please describe other receipt(s):
Number of Employees:
Full Time:
Part Time:
Off-Premises Parking?
- Yes
- No
If yes, please provide address:
On-Premises Banquets?
- Yes
- No
If yes, estimated number of occasions annually:
Off-Premises Catering Exposure?
- Yes
- No
If yes, percentage of total receipts:
If yes, please describe the exposure:
Delivery? If yes, please complete supplemental application.
- Yes
- No
Percentage of total sales generated by delivery:
Average number of deliveries per week:
Any trap doors on premises?
- Yes
- No
Any other on or off-premises exposures?
- Yes
- No
If yes, please describe:
Applicant is located:
- Inside City Limits
- Outside City Limits
Hours of operation: (Days and Time)
Kitchen Fire Protection
Type of Cooking:
- Full
- Limited
- None
Type of Fire Suppression System:
- Wet
- Dry
- Water Based
- Solid Fuel
Claims Section
- No Claims to Report
Please list all claims for each line for the past three years. Please include the date of loss, type of loss and amount paid/reserved:
Date of Loss Type of Loss Amount Paid / Reserved
Optional Coverage Limits
Deductible: $
Broadened Property Endorsement?
- Yes
- No
Business Personal Property Off Premises: $
Employee Dishonesty: $
Forgery: $
Outdoor Signs/Awnings/Tents: $
Utility Services Time Element: $
Money & Securities – Inside: $
Money & Securities – Outside: $
Food Contamination: $
Additional Advertising Expense: $
Spoilage: $
Flagpoles: $
Fine Arts: $
Fine Arts Owned by Others: $
Canopies: $
Transit: $
Valet Parking?
- Yes
- No
If yes, is Garagekeepers coverage needed?
- Yes
- No
If yes:
Comprehensive / Collision Limit: Collision Ded: Comp Ded:
Earthquake coverage needed?
- Yes
- No
Deductible: (%)
Other:
If the primary business operations are closed for more than 30 consecutive days, please complete the following:
Is the water supply shut off?
- Yes
- No
Is the water system drained?
- Yes
- No
Is the system winterized if closed during the winter?
- Yes
- No
Is heat to the building maintained?
- Yes
- No
Is there a fire suppression system?
- Yes
- No
Are there any alarm systems?
- Yes
- No
Are the perishable foods removed from the premises?
- Yes
- No
Entertainment Section
Is there any type of entertainment at this location?
- Yes
- No
If yes, type of entertainment:
- Band
- DJ
- Karaoke
- Solo Entertainer
- Other
If Other, please describe:
Frequency of entertainment:
Is there a dance floor?
- Yes
- No
Average age of clientele (indicate approximate percentage)
Under 21: 21 – 25: 26 – 30: 31 – 40: Over 40:
Is there security of any type (Off-duty police, third party security or in-house employees)?
- Yes
- No
Are there written procedures in place for security personnel?
- Yes
- No
Do they carry any of the following: Mace, billy clubs, restraint devices, tasers or other?
- Yes
- No
How many altercations have occurred on premises in the last 12 months?
Is there a cover charge?
- Yes
- No
If yes, how much?
Does the described premises have any of the following? Please indicate the number of items where applicable.
Dart boards Pool tables Foosball tables
Does the described premises have any of the following? Please indicate the number of items where applicable.
Shuffleboard Horseshoes Video games
Does the described premises have any of the following? Please indicate the number of items where applicable.
Jukeboxes Volleyball courts Poker machines
If described premises has other items, please describe:
Property Information
Square Footage
Building Total:
Occupied Area:
Basement:
Public Area:
# of Apartments:
Other Area:
Please describe Other Area:
Building Limit:
Inflation Percentage:
Type:
- ACV
- RC
- FRC
Deductible:
Business Personal Property Limit:
Type:
- ACV
- RC
- FRC
Tenants Improvements & Betterments Limit:
Type:
- ACV
- RC
- FRC
Year Built:
Construction Type:
# of Stories:
Updates – please indicate the year of any update(s):
Wiring Roofing Plumbing Heating
Sprinkler System?
- Yes
- No
If yes, percentage of sprinkler coverage:
Security Cameras
Security Cameras?
- Yes
- No
If yes, please indicate where:
Interior
- All public areas are covered by security cameras
- All interior areas are covered by security cameras, including storage areas
Exterior
- Limited exterior areas are covered by security cameras
- All exterior areas are covered by security cameras, including all parking lot area(s)
Length of time recordings kept before the tape/disc is erased, copied over, discarded or destroyed?
- Hours
- Days
- Weeks
- Months
Crime Information
Maximum Cash With Messenger:
Money on Premises Overnight:
Frequency of Deposits:
Please describe any other protection (Lighting, fences, watchpersons, etc.):
Financial Information
Is entity currently involved in or has entity ever been involved in any of the following (check all applicable)
- Bankruptcy
- Business Failures
- Foreclosure
- Litigation
- Tax Liens
- None
Please explain for any boxes checked:
Mortgagee Name:
Check here if none:
- None
Mortgagee Mailing Address:
Street Address Address Line 2 City State ZIP Code
Additional Insured Name:
Additional Insured Mailing Address:
Street Address Address Line 2 City State ZIP Code
Liquor Liability Section
Does applicant serve alcohol?
- Yes
- No
If yes, this entire section must be completed.
Limit of Insurance, Each Common Cause:
Does the applicant have a liquor license?
- Yes
- No
If yes, type of license:
Does applicant regularly close before time on license?
- Yes
- No
If yes, please describe:
What time does the kitchen close for full food service?
Does the applicant sell package goods?
- Yes
- No
If yes, what percentage of liquor receipts?
Are all employees required to complete an alcohol awareness training program?
- Yes
- No
If yes, please describe:
Does applicant have a written policy on selling/serving alcohol?
- Yes
- No
Does applicant have a policy to call taxi or provide rides for those who are intoxicated?
- Yes
- No
Is documentation kept on each incident?
- Yes
- No
Has applicant ever had a liquor violation, suspended license or revoked license?
- Yes
- No
If yes, please explain:
Does applicant have a designated driver program in place?
- Yes
- No
If yes, please describe:
Are minors allowed on premises?
- Yes
- No
Does applicant have an age verification system?
- Yes
- No
If yes, please describe:
Have there been any police calls to this location?
- Yes
- No
If yes, please describe:
What is the regular price for a bottle of domestic beer?
What is the regular price for a well drink?
Workers Compensation Section
Employer’s Liability Limit:
Individual(s) to be Included:
Individual(s) to be Excluded:
Claims Contact Person:
Phone
Audit Contact Person:
Phone
Class Code Annual Payroll Class Code Annual Payroll
Minnesota Corporate Payroll Hours:
Target Premium:
Umbrella Section
Limit of Insurance:
Employer’s Liability Information
Company
Policy Number
Effective Dates of Policy
Policy Limits
Automobile Liability Information
Company
Policy Number
Effective Dates of Policy
Policy Limits
Liability Only Premium
Auto Symbol(s)
Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties (Not applicable in CO, DC, FL, HI, KS, MA, MN, NE, OH, OK, OR, VT or WA.)

It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. (Applicable to CO.)

Date of Loss	Type of Loss	Amount Paid / Reserved

Class Code	Annual Payroll	Class Code	Annual Payroll

New Business Application

Agency Information

Applicant Information

Policy Information

Liability Section

Kitchen Fire Protection

Claims Section

Optional Coverage Limits

Entertainment Section

Property Information

Crime Information

Financial Information

Liquor Liability Section

Workers Compensation Section

Umbrella Section