| Name * | |
| E-mail Address: * | |
| Business Name | |
| Contact Phone | |
| Fax | |
| Mailing Address * | |
| City * | |
| State * | |
| Zip Code * | |
| Business Address (If Different From Mailing) | |
| Business Legal Structure | |
| Name of Your Current Insurance Company | |
| How Long Have You Been With That Company? | |
| Desired Effective Date | |
| Any Claims In The Last 3 Years? | |
| If Yes, Please Explain | |
| Number of Years In Business Under Current Ownership | |
| At This Location? | |
| Has The Owner Ever Been Involved In A Bankruptcy Or Business Failure? | Yes
No |
| If Needed, Can Financial Statements Be Provided Prior To Binding? | Yes
No |
| Gross Sales For The Past Three Years (Enter as Year/Food Sales ($)/Liquor Sales ($) | |
| What Are The Hours of Operation? | |
| Is The Business Seasonal? | Yes
No |
| If Yes, What Are The Months Of Operation? | |
| Is There A Bar or Lounge? | Yes
No |
| If Yes, Describe | |
| Happy Hour? | Yes
No |
| If Liquor Is Served, Describe The Training Protocol For Liquor Servers | |
| Is There Live Entertainment? | Yes
No |
| If Yes, Describe (Nights Per Week, Hours, Etc.) | |
| Is There A Dance Floor? | Yes
No |
| If Yes, What Is Its Size? | |
| Are There Any Operations Away From The Premises, Such As Catering? | Yes
No |
| If Yes, Explain | |
| Any Tableside Cooking or Food Preparation? | Yes
No |
| Was The Building Originally Built As A Restaurant? | Yes
No |
| If No, Has The Wiring, etc. Been Updated For Restaurant Occupancy? | Yes
No |
| When? | |
| Which Floor Is The Restaurant Located On? | |
| Maximum Seating Capacity Of Restaurant | |
| Maximum Seating Capacity of Lounge, If Any | |
| Number of Exits | |
| Are All Exits Free Of Obstructions, Lighted, and Marked With Exit Signs? | Yes
No |
| Is There Emergency Lighting? | Yes
No |
| Ever Been Cited By The Board of Health? | Yes
No |
| If Yes, Explain | |
| Rate Your Housekeeping | |
| Is There Valet Parking? | Yes
No |
| Is There A Coat Check Room? | Yes
No |
| Are All Areas Over Range Grills, Fryers, All Other Cooking Surfaces And Hoods And Ducts Protected By A ULB00 Compliant Automatic Fire Extinguishing System? | Yes
No |
| Is There A Maintenance Agreement To Regulary Inspect And Service The System? | Yes
No |
| Are The Employees Trained In The Use Of The Automatic Extinguishing System And Portable Fire Extinguishers? | Yes
No |
| Is There A Maintenance Agreement With An Outside Firm To Clean The Hood And Duct System? | Yes
No |
| If No, Explain | |
| How Often Are The Grease Filters Cleaned By The Employees? | |
| Additional Comments or Questions | |
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