RESTAURANT/BAR/TAVERN APPLICATION
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” Name of Applicant:
Mailing Address:
Contact Name: Contact Phone:
Business Phone: Business Fax:
E-mail: Web site Address:
Business Location (if different than the above mailing address):
City: State: Zip:
Inspection contact name and telephone number: Audit contact name and telephone number:
Form of business: Individual Partnership Corporation Other:
PROPOSED EFFECTIVE DATE: PROPOSED EXPIRATION DATE:
Business Operations:
1. Total receipts from all operations: $
2. Provide percentage of total receipts for each exposure listed below:
Restaurant ... % Bowling Alley ... % Bar ... % Strip/Adult Entertainment ... % Tavern ... % Comedy Club ... % Nightclub ... % Brew Pub ... % Biker Bar ... % Private/Fraternal Club ... % Pool Hall ... % Other(Explain): ... % 3. Is this a new venture? ... Yes No
Additional operations on premises:
4. Provide number of apartment units on premises:
5. Is building or premises Lessor’s Risk Only? ... Yes No
a. If yes, provide: total square feet: Applicant maintains: square feet
Type of occupancy: Name of Lessor Risk Tenant:
b. Does Applicant hold harmless agreement? ... Yes No If yes: Does Applicant hold a Certificate of Insurance? ... Yes No If yes: Is Applicant named as an additional insured on Lessee’s policy? ... Yes No
6. Square feet of business office: 7. Square feet of warehouse:
8. Any gift shop receipts? ... Yes No If yes, provide receipts.
9. Any other operations not identified above? ... Yes No Explain:
10. PRIOR CARRIER INFORMATION
Year: Year: Year: Year: Year:
Carrier Policy Number Property Coverage General Liability Liquor Liability Crime Total Premium
11. LOSS HISTORY—THREE YEAR PERIOD
Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give rise to claims for the prior five years.
Check box if no claims.
Date of Loss
Type of
Coverage Description of Loss Amount Paid
Amount Reserved Claim Status (Open or Closed)
12. Is current carrier willing to renew? ... Yes No 13. Has applicant ever been cancelled or non-renewed for any reason other than non-payment, carrier’s
termination of a class, program or state (Not applicable in Missouri)? ... Yes No If yes, provide reason or reasons for cancellation or non-renewal:
14. Any assault and battery claims in the past three years? ... Yes No 15. Any mold claims in the past three years? ... Yes No 16. Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or
negli-gent hiring? ... Yes No 17. Any non-owned or hired auto liability claims in the past three years? ... Yes No 18. Any bankruptcies, tax or credit liens against the applicant in the past five years? ... Yes No 19. During the past ten years, has any applicant been convicted of an arson crime? ... Yes No
20. Provide loss details of all losses in excess of $2500:
Property Information
1. Location (Physical address):
Subject of Insurance Amount Co-Insurance
Percent Valuation Coverage Form Deductible Building % Tenant Improvements & Betterments % Business Personal Property % Business Income: With Extra Expense Without Extra Expense
Coinsurance percentage or Monthly Limitation %
%
Property Enhancement Endorsement (available with Causes Of Loss Special Form only) ... Yes No NOTE: A minimum deductible of $500 applies to this coverage. This endorsement provides additional limits of insur-ance as follows:
Accounts Receivable—$25,000 Computer Equipment—$25,000 Outside Signs—$10,000
Spoilage—$25,000 Valuable Papers—$25,000 Fine Arts—$15,000
Money & Securities—$25,000 Employee Dishonesty—$10,000 Property of Others—$10,000 Back-up of Sewer & Drains—$15,000 Outdoor Property—$10,000 Property in Transit—$15,000
Construction Type: Protection Class: No. of stories: Year Built: Area Occupied by Applicant:
2. Provide year of building updates: Partial or complete updates:
Electricity Plumbing Roofing HVAC
3. Building entirely sprinklered? ... Yes No If no, is applicant’s business areas sprinklered? ... Yes No 4. Are there any lakes, ponds or boat slips? ... Yes No 5. Are there smoke detectors? ... Yes No
If yes, hard wired or battery operated?
6. Are there fire alarms? ... Yes No If yes, central station, local or pull alarms operated?
7. Are there burglar alarms? ... Yes No If Yes, central station or local operated?
8. Is there aluminum wiring on premises? Yes No
If yes, describe:
9. Is the aluminum wiring repaired? ... Yes No Describe:
10. Are all fire exits clearly marked? ... Yes No 11. Is there a secondary means of egress on each floor? ... Yes No 12. Emergency lightning in common areas? ... Yes No 13. Are fire extinguishers tagged and serviced within past twelve (12) months? ... Yes No
If yes, by whom:
14. Is there a formal safety program in place? ... Yes No 15. Is business operation seasonal? ... Yes No
If yes, date business closes: Date business reopens:
16. What percentage of the building is in course of construction or being renovated? ... % 17. What percentage of the building is vacant? ... % 18. Are pyrotechnic or foam machines used? ... Yes No 19. Is sawdust used on the floor for esthetics? ... Yes No 20. Are circuit breakers used in the building? ... Yes No 21. Any knob and tube wiring in building? ... Yes No 22. Is roof flat? ... Yes No 23. Roof construction (shake, shingle or tile)?
24. Plumbing material used (e.g. PVC, copper, iron, lead, etc.)?
25. Is there a current service contract for maintenance of refrigeration equipment? ... Yes No If yes, how often is service performed?
26. Restaurant/Cooking Operations: Check the box if no cooking on premises
a. Are hoods and ducts equipped with filters? ... Yes No b. Any sub-contracted cooking facilities? ... Yes No c. Type of cooking (check all that apply): Deep Fat Fryers Pizza Oven Griddles Microwave
BBQ Grill Pit
d. Are hoods and ducts equipped with filters? ... Yes No e. Any tableside cooking? ... Yes No f. Are UL approved “K” portable fire extinguishers mounted and accessible to cooking areas? ... Yes No 27. Is raw seafood served? ... Yes No
If yes, describe:
28. Are banquet facilities available? ... Yes No If yes, square footage:
30. Is there a UL certified automatic suppression system over all cooking surfaces and deep fat fryers? ... Yes No If yes, does system have an automatic shut-off? ... Yes No If yes, provide type of system? ... Wet Dry If yes, does the UL certified automatic suppression system include an automatic gas or electric shut-off
with a manual pull capacity? ... Yes No If no, explain:
a. Is there an independent cleaning contract for hoods and ducts? ... Yes No If yes, how often is system cleaned?
b. Is there an independent cleaning contract for the automatic extinguishing system? ... Yes No If yes, how often is system cleaned?
c. Have there been any Health Department violations? ... Yes No If yes, describe:
Crime Information
31. Any background checks on employees prior to hiring? ... Yes No 32. Are bank deposits made frequently? ... Yes No
If yes, how often during the day?
If yes, at irregular times? ... Yes No 33. Is there a drop safe? ... Yes No
If yes, who has keys?
34. Maximum amount of money at each cash register:
35. Any twenty-four (24) hour operation? ... Yes No If yes, camera surveillances at door? ... Yes No If yes, is there a buzzer to allow entry after 1:00 a.m.? ... Yes No
General Liability Information
Coverage Limits of
Liability
Coverage Limits of
Liability
Each Occurrence Medical Expense (any one person)
General Aggregate Liquor Legal (Each Comm. Cause)
Product/Completed Operations Aggregate Liquor Legal (Annual Aggregate)
Personal and Advertising Injury Non-owned and Hired Auto
Fire Damage (any one premise) Employers Liability
Additional Interests (Additional Insureds, if acceptable, are subject to $100 each, plus any applicable tax): Name:
Attn.:
Mailing Address:
Indicate type of interest: Certificate Holder only Additional Insured and Certificate Holder Loss Payee Contract of Sale Mortgagee
Gross Sales by Category—Projected for Policy Term
Food Beer/Wine/Liquor—Off Premises
Beer & Wine (On premises consumption) Off Premises Catering
Other Liquor (On premises) Other Receipts
Receipts—Current Year Total Projected Receipts
Total Receipts—Last Year Source of Other Receipts
Total Receipts—Prior Year
1. How many days per week is this location open? 2. What time does the business open?
3. What is the latest closing time?
4. What is the building’s legal maximum occupancy established by the fire marshal or fire department? 5. Average number of patrons on premises during peak hours:
6. Maximum number of patrons on premises at any one time:
7. Are all exists equipped with panic door hardware? ... Yes No 8. Are all exists kept unlocked during business hours? ... Yes No 9. Number of exits:
10. Are all means of egress marked with lighted exist signs? ... Yes No 11. Is there emergency lighting? ... Yes No 12. What area of the parking lot is under the control of the applicant?
13. Any valet parking? ... Yes No
14. Describe surface of parking lot: Dirt Gravel Concrete Asphalt No parking lot
Other: Explain
15. Number of employees by category:
Managers: Bartenders: Waiter/Waitresses:
Security/Bouncers:
Armed? ... Yes No If not armed, are armed guards contracted? ... Yes No 16. Are firearms kept or permitted on the premises? ... Yes No 17. Number of times per year police are called to the business location?
If called, provide details:
18. Does applicant sponsor any athletic activities events or teams? ... Yes No 19. Is there a children’s designated play area? ... Yes No 20. Any volleyball courts, basketball courts or batting cages on premises? ... Yes No 21. Any guard dogs or any animal on premises during or after business hours? ... Yes No
Entertainment Liability Information
Entertainment: Check box if no entertainment on premises and skip to next section.
22. Is there a dance floor? ... Yes No If yes, dance floor square footage:
23. Any mechanical devices on premises? ... Yes No If yes, describe:
24. Any gambling devices, slots or tables on premises? ... Yes No If yes, describe:
25. Any pool or billiard tables on premises? ... Yes No If yes, describe:
26. Any athletic events sponsored on or off premises? ... Yes No If yes, describe:
27. Any promotional events, such as Teen Night, Wet T-Shirt or Foam Contest, on or off premises? ... Yes No If yes, describe:
28. Any special activities, such as mud wrestling, bungee jumping, velcro suits or mosh pits on or off
premises? ... Yes No If yes, describe:
29. Other special or promotional activities? ... Yes No If yes, describe:
Live Entertainment Information
30. LiveEntertainment: Check box if no entertainment on premises and skip to next section.
31. Is a DJ provided? ... Yes No If yes, describe:
32. Any karaoke type entertainment? ... Yes No If yes, describe:
33. Any topless or go-go dancing? ... Yes No If yes, describe:
34. Any comedians or stand-up entertainers provided? ... Yes No If yes, describe:
35. Any live performers: . Country? ... Yes No. If yes, number of nights per week Piano/solo acts? ... Yes No. If yes, number of nights per week Rock/disco? ... Yes No. If yes, number of nights per week
Other? ... Yes No. If yes, number of nights per week and describe:
36. Any national known performers provided? ... Yes No If yes, describe:
37. Any promoters? ... Yes No If yes, describe:
38. Any special effects: Lighting/Sound? Yes No
Smoke? ... Yes No Pyrotechnics? ... Yes No Other live entertainment? ... Yes No If yes, describe:
39. Is business considered a concert venue? ... Yes No If yes, describe:
40. Are the premises sublet or rented out for use by others as a nightclub? ... Yes No If yes, describe:
41. Can tickets for shows/bands be purchased on line or at the door?
Liquor Liability Information
42. Liquor Liability: Check box if coverage not requested and skip to next section. 43. Liquor Liability Coverage:
Limits of Insurance: $300,000 $500,000 $1,000,000 Other:
44. Effective date: Liquor License number: Type: Beer & Wine Full Liquor
45. Any special promotions/drinks, such special consumption promotions such as ladies night, 2 for 1, etc? Yes No If yes, describe:
46. Are customers allowed to bring their own bottles or liquor set ups? ... Yes No 47. Any flaming drinks served? ... Yes No
If yes, describe:
48. Provide customers demographic age by percentage: under 25: % 25 -34 % 35-54 %
over 54 %.
49. Are patrons under twenty-one (21) allowed on premises? ... Yes No
50. Provide drink prices by type: Cocktails: $ to $ Beer: $ to $
Wine: $ to $
51. Any off premises dispensing of alcoholic beverages for off-premises events? ... Yes No 52. Has applicant, any owner, partner or officer of licensee ever had a liquor license revoked or
suspended? ... Yes No If yes, describe:
53. Any liquor violations in past three years? ... Yes No If yes, how many:
54. Have authorities been called to your premises for any reason during the past five years? ... Yes No If yes, describe:
55. Is training or guidance provided for servers in the handling of minors or intoxicated customers? ... Yes No If yes, are there written guidelines for handling minors and intoxicated customers? ... Yes No If yes, what percentage of servers have training? ... % 56. Are servers trained in tips/tops within sixty (60) days of employment? ... Yes No 57. Are customers served without checking age identity? ... Yes No If no, are there written guidelines? ... Yes No
58. Is a “bouncer” employed? ... Yes No 59. Does applicant currently carry Liquor Liability Insurance? ... Yes No
If yes, provide the following: Name of Carrier: ; Limit of Liability:
Policy Type: Occurrence Form Claims Made Form
60. Has applicant had Liquor Liability Insurance coverage denied, canceled or non-renewed during the last
three years (Not applicable in Missouri)? ... Yes No If yes, provide details:
61. Has applicant had any past incident that may give rise to a claim? ... Yes No If yes, provide details, including possible liability amounts payable:
Hired and Non-Owned Auto Information
62. Hired and Non-Owned Auto Coverage: Check box if coverage not desired and skip to next section. 63. Does applicant verify each employee driving for business purposes has a valid government issued
driver’s license and carries sufficient personal insurance in accordance with minimum state insurance
requirements? ... Yes No 64. Does applicant prohibit business driving rights for any individual with prior incidence of license
suspen-sions, revocations or DUI of alcohol or illegal drugs ? ... Yes No 65. Is off-site catering or delivery service provided? ... Yes No
If yes, how many trips are made per month?
66. Any hired and non-owned auto losses in past five years? ... Yes No 67. Are employees required to use their personal vehicles to conduct applicant’s business? ... Yes No
If yes, is evidence of auto liability insurance such as a Certificate of Insurance obtained and maintained
on file? ... Yes No 68. How often are MVRs and auto liability insurance reviewed to ensure both are valid and current?
Valet Parking Information
69. Valet Parking: Check box if coverage not requested and skip Questions 69 through 72.
70. Is valet parking offered? ... Yes No If yes, is valet parking performed by the applicant’s employees? ... Yes No 71. Are valet parking attendants driving records checked? ... Yes No 72. Is valet parking performed by a subcontractor? ... Yes No
If yes, the following questions must be answered:
a. Does outside firm have insurance coverage in force to cover liability arising out of valet parking
in-cluding physical damage to customer’s autos? ... Yes No b. Is applicant included as an insured under the outside firm’s garage and garagekeepers insurance? . Yes No 73. Is the business operation in compliance with ADA requirements? ... Yes No
THE APPLICANT REPRESENTS THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT TO THE BEST OF HIS OR HER KNOWLEDGE, AND THAT NO MATERIAL OR RELEVANT FACTS HAVE BEEN SUPPRESSED OR MISSTATED AND AGREE THAT THE POLICY, IF ISSUED, WILL BE ISSUED ON THE RELIANCE OF SUCH REPRESENTATIONS.
Applicant acknowledges a continuing obligation to report to us or your agent as soon as practicable any material changes in the facts or statements above, and in each supplementary application, which applicant becomes aware after signing the application.
Completion of application or tendering of premium does not bind coverage. Application is subject to the company’s guide-lines. Applicant’s acceptance of company’s quotation is required prior to binding coverage and policy issuance. It is agreed that this application shall be the basis of the contract of insurance should a policy be issued and it will be attached to the policy.
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-mation contained herein shall be the basis of the contract should a policy be issued.
FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Not applicable in Nebraska, Oregon and Vermont.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-formation to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award pay-able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insur-er files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a fel-ony in the third degree.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be sub-ject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading infor-mation is guilty of a felony.
NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
FRAUD WARNING (Applicable in Tennessee, Virginia and Washington): It is a crime to knowingly provide false, complete or misleading information to an insurance company for the purpose of defrauding the company. Penalties in-clude imprisonment, fines and denial of insurance benefits.
NOTICE TO NEW YORK APPLICANTS (Other than automobile): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
I/We hereby declare that the above statements and particulars are true and I/We agree that this application shall be the basis of the contract with the insurance company. Any missing or erroneous information in this Application may jeopardize coverage in the event of a claim under any policy issued by us.
APPLICANT’S NAME:
APPLICANT’S SIGNATURE: DATE:
(Must be signed by an authorized owner, partner or executive officer)
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only) IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning character, general reputation, personal characteristics and mode of living. Upon written request, additional
