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   $

Contents (90%) Replacement Value   Special Form   $

Business Income   %   $

Per Claim Deductible     $1,000

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:
Fire/Protection:	Sprinkler       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
		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

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