MINNESOTA LIQUOR LIABILITY ASSIGNED RISK PLAN Administrated by:

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1 MINNESOTA LIQUOR LIABILITY ASSIGNED RISK PLAN Administrated by: Minnesota Joint Underwriting Association Portland Ave. S., Ste 190 Burnsville, MN (800) or (952) Fax: (952) Enclosed is an Application for Coverage and rate schedule for the Minnesota Liquor Liability Assigned Risk Plan. (The Plan) If you desire, you may make additional copies of the blank application form for your future use. No application will be accepted unless the application is fully completed, legible and signed by an authorized representative of the Applicant (License Holder). The agent may NOT sign on behalf of the License Holder. The following MUST accompany the completed application: 1. Documentation of the applicant s gross receipts derived from liquor sales detailed by month for previous 12 months. (Must match amounts reported to State Sales Tax Department.) 2. A copy of the applicant s current liquor license(s) clearly indicating the name of the Legal Licensee and issuing authority. 3. Written notice of refusal (rejection) from an Insurer. A written quote provided by an insurer at a rate in excess of 120% of plan rates for similar coverage is deemed to be a written rejection. 4. Copy of ordinance if Increased Limits are required by City or licensing authority. 5. Full premium payment or 50% of annual premium if the annual premium is more than $2, % of premium for special events. The above required documentation should be submitted directly to the Minnesota Joint Underwriting Association (MJUA). Checks should be made payable to MJUA. The remaining 50% of the premium MUST be received by the MJUA within five months of the effective date of coverage in order to avoid cancellation (an invoice will be mailed to the named insured). Agent commission is 10%. A qualifying liquor vendor can choose to submit application direct to the Plan without the services of an agent. Agents do NOT have binding authority on behalf of the Plan. Page 1

2 MINNESOTA JOINT UNDERWRITING ASSOCIATION PORTLAND AVE S, STE 190 BURNSVILLE, MN (800) or (952) fax: (952) MINIMUM LIMITS OF LIABILITY PER MINNESOTA STATUTES Coverage Limits of Liability Bodily Injury Property Damage Loss of Means of Support Pecuniary Loss $ 10,000 each occurrence Annual Aggregate $300,000 ANNUAL RATES FOR ABOVE LIMITS (Per $100 of Liquor Sales) Classification Rate Minimum Premium Off Sale Only $0.42 $250 (up to $59,523 in liquor sales) Restaurants/Sports Clubs $1.46 $500 (up to $34,246 in liquor sales) (Liquor sales LESS than food sales) Bars/Restaurants $3.74 $750 (up to $20,053 in liquor sales) Sports Clubs/Wineries Combined On/Off Sale (Liquor sales MORE than food sales) Special Events $5.00 $125/day ($2500/day in liquor sales) Rate Scale for Indicated Number of Claims (reserved or paid) in Last Three Years Bar Restaurant Off Sale No Claims Claim Claims Claims Claims RATES EFFECTIVE 4/1/03 Page 2

3 MINNESOTA JOINT UNDERWRITING ASSOCIATION PORTLAND AVE S STE 190 BURNSVILLE, MN MAIN: FAX: APPLICATION FOR LIQUOR LIABILITY COVERAGE Coverage will not be bound if the correct premium payment, written rejection (or quote in excess of 20% above plan rate), current license, and required documentation of liquor receipts are not attached. Coverage cannot be bound prior to 12:01 a.m. the day following receipt of the above. Legal Name of Applicant (As shown on license) Trade Name (DBA) Mailing Address City, State, Zip County Phone Operating Location: Classification: Primary Nature of Business: Check all applicable: Restaurant Sports Club Bar Winery Special Event Other (Explain Classification): NOTE: OFF SALE FACILITITES MUST HAVE SEPARATE ENTRANCE TO QUALIFY FOR OFF SALE RATE Off Sale Only On/Off Sales On Sale Only Total receipts of entire establishment: $ Gross receipts from Liquor Sales: $ Gross receipts from OFF SALE: $ ON SALE: $ License in effect? Yes No Explanation: Licensing Authority: Address: City: State: MN Zip Code: License Number: Effective Date: Expiration Date: Page 3

4 Has license ever been revoked/suspended? Yes No If yes, list date and explanation: CAUTION: Any misrepresentation made by the applicant can void coverage or result in cancellation. False or misleading answers to the following questions would constitute gross misrepresentation and VOID COVERAGE. A Loss does not include notice of claim. Unless, following receipt of notice, your insurer or you in the event you were self-insured made a payment in settlement of the claim or the insurer established a reserve for the loss. A Violation includes any conviction on a charge brought against the applicant or any employee or agent of the applicant arising out of the illegal sale of liquor. You must submit LOSS RUNS from previous carriers, if applicable, for three years preceding your request for coverage. In the event you were self-insured, please submit a listing of all claims made against your establishment during your period of self-insurance. Loss history must be submitted for each of the three years. Coverage Information: Liquor Liability Coverage currently in effect? Yes No Previous three years of insurance coverage prior to effective date of coverage desired: Carrier Address Policy # Policy Period Losses and Violations Has Liquor Liability Coverage ever been cancelled? Yes No If yes, explain why: Coverage is requested to take effect at 12:01 A.M. on Applicant agrees to permit contract administrator to audit applicant s books and records during normal working hours to extent deemed necessary to verify information relating to receipts from Liquor Sales and/or other matters concerning the coverage applied for. Signature of Applicant Date Telephone Number Agency Name: Agent: Agent Address: City, State, Zip: Phone: Page 4

5 INCREASED LIMITS FACTORS Note Increased limits are available only to vendors who are REQUIRED to carry increased limits by their local licensing authority. The MJUA requires that it be provided with a copy of the ordinance at the same time an Application is submitted. The factors shown below must be applied to the rates and minimum premiums shown for the applicable classification on previous page. Special Event Special Event Rate Per Increased Limits Factor Min. Premium $100 of Sales 100/100/20/ $ $5.70/ /200/40/ $ $6.35/ /300/60/ $ $6.85/ /500/100/ $ $7.50/ /1000/100/1M 1.52 $ $7.60/100 1M/1M/300/1M 1.64 $ $8.20/ /1M/60/1M 1.42 $ $7.10/ /600/40/ $ $6.55/100 1M/2M/300/2M 1.66 $ $8.32/100 Special Event Coverage This coverage is available through the MJUA subject to the same requirements and conditions applicable to other risks. The MJUA requires: 1. a fully completed application signed by the applicant/licensee; 2. a copy of applicant s liquor license or of the application for a pending license; 3. documentation of liquor receipts; 4. a copy of the ordinance if increased limits are required; % of the premium must accompany the application. The rate for the minimum limits of liability under Minnesota Statutes is $5 per $100 of gross liquor receipts. Minimum premium is $125/day for events of 4 days or less. For events of 5 days or more, the minimum premium is $625. The $5 rate applies to sales in excess of sales necessary to generate the minimum premium. You must maintain daily records of receipts for events of less than 5 days. A written rejection is not presently required for a Special Event. Effective Date Coverage cannot be bound earlier than 12:01 a.m. the day following receipt by the MJUA of the application, ALL required documentation, and the deposit premium. AGENTS DO NOT HAVE BINDING AUTHORITY. Page 5