Home > Restaurant Full Name of ApplicantAddress of ApplicantCityCountyStateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYZip CodeMailing Address (If Different)Owners Name (Principal)SS or EIN #Home AddressHome Phone #Business Phone #Effective DateCurrent CompanyCurrent PremiumAny policy or coverage declined, cancelled or non-renewed during three prior years? (not applicable in Missouri)YesNoBusiness InformationApplicant is a :CorporationPartnershipIndividualOtherApplicant is a :RestaurantDinerTavernNight ClubBanquet HallFine DiningOther (Please Specify)# of Years at this Location# of years in Restaurant Business *If less than 3 years at this Location, list previous experience *Building Owner - Name *Building Owner - Address *Include Building Owner as Named Insured as interest may appear? *Please select an optionYesNoFinancial InformationIs Owner or Corporation now or ever involved in : *Please select an optionBankruptciesForeclosuresTax LiensBusiness FailuresAny LitigationsIf Yes, Please ExplainAdditional InterestsMortgagee and Address *Additional Insureds *Loss PayeesProperty SectionBuilding LimitCo-Ins %ACVR/CDeductibleContents LimitCo-Ins %ACVR/CDeductibleBusiness Income Limit *Contribution or Co-Ins % *DeductibleBusiness Income ALS *Cause of Loss :BasicSpecialSpecial with Theft on Contents OnlyBusiness Income with Extra ExpenseYesNoIf not answered, will be Rated withoutLoss of Rents Limit *Co-Ins %Cause of Loss *DeductibleSign LimitTypeWordingDeductibleGlass Coverage NeededYesNoIf "Yes", provide valueCrime Coverage Form C LimitDeductibleEmployee Dishonesty LimitDeductibleOther Property CoveragesMultiple Occupancies? If so, List:Liability SectionGeneral Liability LimitAggregateLiquor Liability LimitAggregateReceipts FoodReceipts LiquorReceipts OtherReceipts TotalSquare Footage Total BuildingSquare Footage RestaurantSquare Footage Apts *Square Footage # AptsOff Premise ParkingYesNoIf "Yes", list address and square footageOn or Off Premise Catering / BanquetYesNoIf "Yes", % of total ReceiptsDescribe Catering OperationLodging Operations Other than ApartmentsYesNoIf "Yes", Describe :Any Other On or Off Premise Exposures NOT Listed AboveYesNoIf "Yes", Describe :Non-Owned AutomobileYesNoIf "Yes", No of EmployeesAny Delivery Use?Valet ParkingYesNoIf "Yes", is Garage Keeper Liability RequiredYesNoIf "Yes", LimitDeductibleAny Elevators or Stairs on Premise?YesNoAny Tableside Cooking?YesNoLiquor Legal Liability SectionDoes Applicant Serve AlcoholYesNoIf Yes, Entire Section MUST be CompletedDoes Applicant Have Liquor LicenseYesNoIf "Yes", Type and #Does Applicant Sell Package GoodsYesNoIf "Yes", % of Liquor Receipts# of Bartenders# of Waiters/WaitressesAvg Length of EmploymentAre Employees Given Liquor TrainingYesNoIf "Yes", Explain Type and When TrainedDoes Applicant Have Written Policy on Serving Alcohol for Employees & CustomersYesNoIs Management Notified Prior to Shutting Off PatronsYesNoIs Documentation Kept on Each IncidentYesNoService Bar Only?YesNo# of Bars on PremisesIs There a Steady Bar ClientelYesNoIs There a Happy HourYesNoReduced Price DrinksYesNoIs a Last Call GivenYesNoIf "Yes", What TimeAre Shots GivenYesNoShots Specials / Shooter GirlsYesNoHave There Been Any Liquor Board ViolationsYesNoIf "Yes", List ALL ViolationsEntertainment SectionEntertainmentYesNoIf "Yes", ENTIRE Section MUST be CompletedNights of WeekFriSatOtherAge of ClientelType of EntertainmentRock GroupDJBand (Any Kind)Go-GoOtherif "Other" (Please Describe)Does a Dance Floor ExistYesNoIf "Yes", Square FootageIs Dancing PermittedYesNoBouncers or DoormenYesNoIf "Yes", Explain WhyAmusement Devices (Pool Tables, Video Games, TVs, etc)YesNoIf "Yes", # and DescriptionClaims SectionProperty Claims *General Liability Claims *Umbrella Claims *Liquor Liability Claims *Umbrella SectionLimit Requested *Business Auto Carrier *Policy # *Premium *Total # of Vehicles *# Private Passenger *# Commercial *Limit *Employers Liability Carrier *Policy # *Limit *Operations SectionIs Applicant Open Now *Please select an optionYesNoIf "No", Explain *Hours of Operation From *Hours of Operation To *Hours of Operation # of Days per Week *Is Applicant a Seasonal Operation *Please select an optionYesNoIf "Yes", Explain *Distance to Ocean or Nearest Body of Water *Physical Plant SectionAge of Building *Age of Construction *Age of # of Stories *Age of Wiring *Age of Plumbing *Age of Heating *Age of Roofing *Smoke Detectors *Please select an optionYesNoIf "Yes", ElectricBattery PowerFire Alarm *Please select an optionYesNoIf "Yes", TypeBurglar Alarm *Please select an optionYesNoIf "Yes", TypeSprinkler System *Please select an optionYesNoIf "Yes", AgeTypeKitchen Fire Protection : UL-300 Wet Chemical Extinguishing System Serviced every 6mos. *Please select an optionYesNoKitchen Fire Protection Above System Covering All Cooking Surfaces *Please select an optionYesNoName of System *Kitchen Fire Protection Automatic Gas or Electric Shut Offs for Cooking *Please select an optionYesNoKitchen Fire Protection Hood and Filters Cleaned Weekly By Staff *Please select an optionYesNoKitchen Fire Protection Hoods and Ducts Over All Cooking Equipment *Please select an optionYesNoKitchen Fire Protection BC Extinguisher Available in Kitchen *Please select an optionYesNoHoods and Ducts Maintenance Contract Schedule # Month *Submit