RESTAURANT INSURANCE QUOTE We would like to provide you with a free, no-obligation restaurant insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only. This form is hosted on a secure server using SSL technology.

 

General Information Name of Business: Contact Name: Mailing Address: City:   State:   Zip: Business Phone:   Fax: Best Time To Call:   AM   PM Contact Email Address:

About Your Business Location Address (if different): City:   State:   Zip: Tax ID#: Type of Risk: Restaurant   Tavern   Fast Food   Bar Other: Applicant is: Individual   Corporation   Partnership   Joint Venture Other: Mortgagee:    Mortgagee Interest: Addt'l Insured:   Addt'l Insured Interest: Effective Date Requested:    Expiration Date:

Coverages Property Building (90%) AC   Broad Form   $ Contents (90%) Replacement Value   Special Form   $ Business Income   %   $ Per Claim Deductible     $250 $500 $1000 Liability General Aggregate   $ Products/Completed Operations Aggregate   $ Per Occurrence   $ 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:   Seating Capacity: Fire/Protection: Sprinkler       Smoke Detector       Fire Extinguisher Square Footage: Total       Customer Food Receipts: $         Liquor Receipts $ Employees: # Full Time:   # Part Time:   Annual Payroll: $ Website: Has the Applicant filed for bankruptcy in the past 5 years? Yes   No Is the Restaurant(s) part of a franchise? Yes   No Is food or alcohol delivered by vehicle? By foot or bicycle? Yes   No Is more than 5% of food served raw fish or meats? Yes   No Do designated employees receive annual training on safe food handling practices? Yes   No Does business participate in any off premises operations, such as parades, contests, festivals or fairs? Yes   No Is there a written procedure to document slips and falls, objects in food, food poisoning and other complaints? Yes   No Are all commercial cooking surfaces and deep fryers protected by a WET automatic chemical extinguishing system? Yes   No Are the outside wall, roof and bell housing free of grease accumulation? Yes   No Is any tableside cooking performed? Yes   No Are there any open pits/hearths or open flame grills? Yes   No Are there Class K fire extinguishers and are they serviced annually? Yes   No Does the business have a formal alcohol awareness training program? Yes   No If yes, what is the name of the program (TIPS, TOPS, etc.) Has applicant ever had their liquor license suspended or revoked? Yes   No Auto used in business? Yes   No

Underwriting Information PROPERTY Building Information Age When Rewired Electrical in Conduit Circuit Breakers Fuse Box Plumbing up to Code Y N Y N Y N Y N Building Condition Housekeeping # of Stories Building Code Violations ExcellentGoodPoor Y N What is Right Exposure What is Left Exposure What is Rear Exposure Free Standing Other Occupancies Distance to Nearest Fire Hydrant Y N If adjacent business is a restaurant, does it have automatic extinguishing devices? Is any portion of the building vacant, unoccupied, or seasonal? (If yes, explain) Y N Y N     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? Y N Y N Y N Exhaust filters are cleaned Is there a professional flue cleaning service used on quarterly contract? DailyWeeklyMonthlyOther Y N   By:   Phone Number: Deep Fat Fryers Automatic Shut Off High Limit Switch Non-Slip Floors Other Kitchen Safety Precautions NoneGasElectricBoth Y N Y N Y N

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

Underwriting Information CRIME Safe Class Type of Locks Maximum Cash in Register Check Cashing Y N Alarm # of Alarms Motion Detectors NoneLocalCentral Y N     How often checked: Name of Alarm Company Any weapons on premises   Ph#: Y N     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 Y N Y N Y N Y N Hours Open Days Closed # of Employees Estimated Annual Payroll Neighborhood From  to StableDeclining Ever suffered earthquake damage Type of food served on premises Flaming Drinks Happy Hours Written policy for serving minors/ intoxicated patrons Y N Y N Y N Y N Exits properly marked Alternate Access Security Guards Parking areas adequately lit/maintained Separate cigarette butt containers Designated Smoking Areas Y N Y N Y N Y N Y N Y N Dart Boards Mechanical Devices Prior problems requiring police Any Liquor Violations Y N Y N Y N If yes: Y N If yes:

Loss History Current / Previous Insurance Company: Policy Number:   Expires: Has any carrier cancelled or refused insurance to this applicant: Y N     If yes: Please describe any losses during the past three (3) years 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, please enter them here.

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