|
|
| 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 |
|
|
|
