VT Liquor Liability Insurance Report

VERMONT LIQUOR LIABILITY INSURANCE REPORT

Department of Financial Regulation

If you have any questions regarding this submission, please contact Rosemary Raszka at 802-828-1686 or Jamie Gile at 802-828-1975. Please note that all submissions should be made electronically using this form. Please do not email forms or mail paper copies to the Department.

Calendar Year *

Countrywide or Vermont?

Company Name: *

NAIC Company Code:

Group Name:

NAIC Group Code:

Company Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Contact Person: *

First Name Last Name

Contact Phone Number: *

Area Code Phone Number

Contact Email:

Do you have business to report? *

Do you have more than one line of business to report? *

Estimates for premiums are acceptable. Please indicate whether or not an esitmate is used for each premium value reported.

(1) Name of Policy or Program:

Please describe. If liquor liability is part of a multi-line policy, the program should be identified. If you write mono-line liquor liability please indicate mono-line.

(2) Premiums Written:

Premiums Written Estimated?

(3) Premiums Earned:

Premiums Earned Estimated?

(4) Claims Losses Paid:

(5) Claims Losses Incurred:

Claims paid the current year less incurred claims reserve prior year plus the incurred claims reserve the current year. Reserves include IBNR reserves.

Include loss adjustment expense.

(6) Number of Policies Written:

(7) Number of Claims Paid:

(8) Number of Claims Incurred:

(9) Loss Ratio:

(5) ÷ (3)

(10) Average Paid Claim:

(4) ÷ (7)

(11) Average Incurred Claim:

(5) ÷ (8)

Please provide totals on a separate line. Estimates for premiums are acceptable. Please indicate whether or not an estimate is used for each premium value reported.

Note 1: Please describe. If liquor liability is part of a multi-line policy, the program should be identified. If you write mono-line liquor liability please indicate mono-line.

Note 2: Claims paid the current year less incurred claims reserve prior year plus the incurred claims reserve the current year. Reserves include IBNR reserves. Include loss adjustment expense.

Please submit the form to indicate that you have no business no report.