Restaurants and Dining Please complete the form below. Business Information Insured Name (Company Name) * Primary Contact Name * First Name Last Name Title * Date of Birth * MM DD YYYY EIN/SS * Date of Formation * MM DD YYYY Email * Insured Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Proposed Effective Date * MM DD YYYY How long has your company been in business? * Have you had any insurance claims in the last five years? * Yes No Restaurant Information Number of Full-time Employees Number of Part-time Employees Do you need workers' compensation? Yes No Property and Equipment Information Do you own or lease the building? Own Lease Construction Type * Brick Masonry Frame Year Constructed Total Square Ft * Fire Alarm/Sprinkler System Installed? Yes No Liquor Exposure Do you sell alcohol? Yes No Is a liquor license in place? Yes No Do you allow BYOB? Yes No % of Gross Receipts from Alcohol * Do servers have TIPS or equivalent training? Yes No Are drink specials offered (e.g., 2-for-1, happy hour)?) Yes No Food Exposure Do you serve food? * Yes No Type of Food Served (e.g., snacks full menu, catered, etc.)) % of Gross Receipts from Food Sales * Do you have an on-site kitchen? Yes No Is food prepared by employees or third-party vendor?? By employees Third-party vendor Do you use deep fryers or open flame cooking equipment? Deep fryers Open flame cooking equipment Is an Ansul or automatic suppression system in place? Ansul Automatic suppression system How often is the hood/duct system cleaned? * Do you have food liability coverage (products/completed operations)? Yes No Loss History and Risk Management Any prior general liability claims in the last five years? Yes No Is video surveillance in use on the property? Yes No Do you use ID scanners at the entrance? Yes No Are bag checks or pat-downs performed on-site? Yes No Maximum Number of Bouncers or Security on Duty Any history of incidents involving weapons or violence? Yes No Coverage General Liability Coverage Amount Requested $500,000 $1,000,000 $2,000,000 Other Property Coverage (building/contents) Business Income Coverage Needed Yes No Do you currently have business insurance? Yes No Amount $ Carrier Information (if applicable) Current Carrier Policy Number Premium Effective Date MM DD YYYY Owner(s) Information Thank you for your submission. One of our agents will contact you shortly.
