INSURANCE   


RESTAURANT INSURANCE QUOTE APPLICATION
Fields marked (*) are mandatory.

General Information

Name of Buisness*
Contact Name*
Mailing Address*
City*
State*
Zip*
Business Phone*
Fax
Best time to Call
Contact Email Address*
Referred By*

About Your Business

Location Address (if different)
City
State
Zip
Type Of Risk
Restaurant
Tavern
Fast Food
Bar
Other
Applicant Is
Individual
Corporation
Partnership
Joint Venture
Other
MortGagee
MortGagee Interest
Additional Insured
Additional Insured Interest
Effective Date Requested
 
Expiration Date
 

Coverages

Property

Building (90%) AC
Broad Form
Value ($)
Contents (90%) Replacment Value
Special Form
Value ($)
Buisness Income
(%)
Value ($)
Per Claim Deductible

Liability

Genereal Aggregate ($)
Products/Completed Operations Aggregate ($)
Per Occurence ($)
Medical Payments ($)
Fire Damage ($)
Liquor Liability ($)

Optional Coverages

Sign (Limits In/Out, $)
Glass (Square Footage, $)
Money/Secs (Limits In/Out, $)
Food Spoilage (Limits In/Out, $)
Other

Rating Information

Construction Type
Fire/Protection
Spinkler
Smoke Detector
Fire Extinguisher
Square Footage
Total
Customer
Food Receipts
($)
Liquor Receipts ($)

Underwriting Information

Property

Building Information
Age
When Rewired
Electrical in Conduit*
Circuit Breakers*
Fuse Box*
Plumbing up to Code*
Building Condition
Housekeeping
# of Stories
Building Code Violation*
What is Right Exposure
What is Left Exposure
What is Rear Exposure
Free Standing*
Other Occupancies
Distance to Near Fire Hydrant
If adjacent business is a resturant, does it have automatic exinguishing devices?
Is any portion of the building vacant, unoccupied, or seasonal
If Yes, Explain
Kitchen Information
Grease Cooking*
Are ducts, hoods, grease filters and surface cooking areas (including deep fat fryers) protected by a U.S. listed automatic fire extinguishing system?*
Is such a system professionally inspected and serviced every 6 months?*
Exhaust filters are cleaned
Is there a professional flue cleaning service used on quarterly contract?*
By
Phone number
Deep Fat Fryers
Automatic Shut Off
High Limit Switch
Non-Slip Floors
Other Kitchen Safety Precautions

Underwriting Information

LIABILITY
Entertainment
Live Entertainment
# of Players
Kind of Music
How Many Nights
Dancing
Disco
# of Pool Tables
# of Game Machines

Underwriting Information

CRIME
Safe Class
Type of Locks
Maximum Cash in Register
Check Cashing
Alarm
# of Alarms
Motion Detectors
If Yes How often checked
Name of Alarm Company
Ph# of Alarm Company
Any weapons on premises
If yes, explain

Underwriting Information

GENERAL
How long at this location
How long in this type business
Operated by Owner
Table Service
Self Service
Any Delivery
Hours Open (From - To)
Days Closed
# of Employees
Estimated Annual Payroll
Neighborhood
Ever suffered earthquake damage
Type of food served on premises
Flaming Drinks
Happy Hours
Written policy for serving minors/intoxicated patrons
Exits properly marked
Alternate Access
Security Guards
Parking areas adequately lit/maintained
Separate cigarette butt containers
Designated Smoking Are as
Dart Boards
Mechanical Devices
Prior problems requiring police
If Yes
Any Liquor Violations
If Yes
Loss History
Current / Previous Insurance Company:
Policy Number
Expires
 
Has any carrier cancelled or refused insurance to this applicant:
If yes
Please describe any losses during the past three (3) years
Date of Loss:
 
Amount:
Description of Loss:
Date of Loss:
 
Amount:
Description of Loss:
Date of Loss:
 
Amount:
Description of Loss:
Date of Loss:
 
Amount:
Description of Loss:
Date of Loss:
 
Amount:
Description of Loss:
Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, plea
 

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