Restaurant - Universal Marketing and management

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Full Name of Applicant

Address of Applicant

City

County

State

Zip Code

Mailing Address (If Different)

Owners Name (Principal)

SS or EIN #

Home Address

Home Phone #

Business Phone #

Effective Date

Current Company

Current Premium

Any policy or coverage declined, cancelled or non-renewed during three prior years? (not applicable in Missouri)

Business Information

Applicant is a :

# 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? *

Financial Information

Is Owner or Corporation now or ever involved in : *

If Yes, Please Explain

Additional Interests

Mortgagee and Address *

Additional Insureds *

Loss Payees

Property Section

Building Limit

Co-Ins %

ACV

R/C

Deductible

Contents Limit

Co-Ins %

ACV

R/C

Deductible

Business Income Limit *

Contribution or Co-Ins % *

Deductible

Business Income ALS *

Cause of Loss :

Business Income with Extra Expense

Loss of Rents Limit *

Co-Ins %

Cause of Loss *

Deductible

Sign Limit

Type

Wording

Deductible

Glass Coverage Needed

If "Yes", provide value

Crime Coverage Form C Limit

Deductible

Employee Dishonesty Limit

Deductible

Other Property Coverages

Multiple Occupancies? If so, List:

Liability Section

General Liability Limit

Aggregate

Liquor Liability Limit

Aggregate

Receipts Food

Receipts Liquor

Receipts Other

Receipts Total

Square Footage Total Building

Square Footage Restaurant

Square Footage Apts *

Square Footage # Apts

Off Premise Parking

If "Yes", list address and square footage

On or Off Premise Catering / Banquet

If "Yes", % of total Receipts

Describe Catering Operation

Lodging Operations Other than Apartments

If "Yes", Describe :

Any Other On or Off Premise Exposures NOT Listed Above

If "Yes", Describe :

Non-Owned Automobile

If "Yes", No of Employees

Any Delivery Use?

Valet Parking

If "Yes", is Garage Keeper Liability Required

If "Yes", Limit

Deductible

Any Elevators or Stairs on Premise?

Any Tableside Cooking?

Liquor Legal Liability Section

Does Applicant Serve AlcoholIf Yes, Entire Section MUST be Completed

Does Applicant Have Liquor License

If "Yes", Type and #

Does Applicant Sell Package Goods

If "Yes", % of Liquor Receipts

# of Bartenders

# of Waiters/Waitresses

Avg Length of Employment

Are Employees Given Liquor Training

If "Yes", Explain Type and When Trained

Does Applicant Have Written Policy on Serving Alcohol for Employees & Customers

Is Management Notified Prior to Shutting Off Patrons

Is Documentation Kept on Each Incident

Service Bar Only?

# of Bars on Premises

Is There a Steady Bar Clientel

Is There a Happy Hour

Reduced Price Drinks

Is a Last Call Given

If "Yes", What Time

Are Shots Given

Shots Specials / Shooter Girls

Have There Been Any Liquor Board Violations

If "Yes", List ALL Violations

Entertainment Section

EntertainmentIf "Yes", ENTIRE Section MUST be Completed

Nights of Week

Other

Age of Clientel

Type of Entertainment

if "Other" (Please Describe)

Does a Dance Floor Exist

If "Yes", Square Footage

Is Dancing Permitted

Bouncers or Doormen

If "Yes", Explain Why

Amusement Devices (Pool Tables, Video Games, TVs, etc)

If "Yes", # and Description

Claims Section

Property Claims *

General Liability Claims *

Umbrella Claims *

Liquor Liability Claims *

Umbrella Section

Limit Requested *

Business Auto Carrier *

Policy # *

Premium *

Total # of Vehicles *

# Private Passenger *

# Commercial *

Limit *

Employers Liability Carrier *

Policy # *

Limit *

Operations Section

Is Applicant Open Now *

If "No", Explain *

Hours of Operation From *

Hours of Operation To *

Hours of Operation # of Days per Week *

Is Applicant a Seasonal Operation *

If "Yes", Explain *

Distance to Ocean or Nearest Body of Water *

Physical Plant Section

Age of Building *

Age of Construction *

Age of # of Stories *

Age of Wiring *

Age of Plumbing *

Age of Heating *

Age of Roofing *

Smoke Detectors *

If "Yes", Electric

Battery Power

Fire Alarm *

If "Yes", Type

Burglar Alarm *

If "Yes", Type

Sprinkler System *

If "Yes", Age

Type

Kitchen Fire Protection : UL-300 Wet Chemical Extinguishing System Serviced every 6mos. *

Kitchen Fire Protection Above System Covering All Cooking Surfaces *

Name of System *

Kitchen Fire Protection Automatic Gas or Electric Shut Offs for Cooking *

Kitchen Fire Protection Hood and Filters Cleaned Weekly By Staff *

Kitchen Fire Protection Hoods and Ducts Over All Cooking Equipment *

Kitchen Fire Protection BC Extinguisher Available in Kitchen *

Hoods and Ducts Maintenance Contract Schedule # Month *