YOUNGS INSURANCE BROKERS INC.
5681 Thorold Stone Road
Niagara Falls, ONL2J 1A1
Phone: (905) 374-7000
Fax: (905) 374-7466 /

Lloyds Restaurant Application

Quote Required by: ______

Producer: / Branch: / Quote Required by:
Legal Business Name:
Mailing Address:
City:Prov:PC: / Contact Information:
Phone:Cell:
Fax:Email:
Name of Owner: / Website:
Form of Business:IndividualPartnershipCorporation
EXPERIENCE
Number of years in business: / Years Prior Experience in field:
Any Claims in Past 5 Years?
Claims Details, include Date of Loss, Nature of Claim, Status of Claim (open or closed), total Payout.:
LOCATION AND MORTGAGEE INFORMATOIN
Risk Address (including postal code – if different from mailing address):
Mortgagee Name and Mailing Address (if applicable)
BUILDING CONSTRUCTIONS AND RENOVATIONS DETAILS
Year Built: / Number of Stories: / Total Area: / Client’s Portion:
Walls / Frame:
Brick Veneer: / HCB:
Metal Clad Frame: / Concrete:
Fire Resistive: / Steel on Steel:
Other:
Floors / Frame/ Wood: / Concrete: / Brick/Stone: / Other:
Basement / Masonry: / Unfinished: / None: / Other:
Roof / Frame on Wood Joists:
Frame on Steel Joists: / Poured Concrete:
Steel Beam: / Steel Deck: / Other
Roof Covering / Asphalt Shingle:
Wood Shakes / Tar and Gravel:
Steel Deck: / Concrete:
Other: / Metal:
Electrical / Breakers / Combination Breakers and Fuses / Fuses / None
Plumbing / Copper: / Plastic: / Other: / None
Heating / Furnace
Roof Mounted HVAC / Boiler
Heat Pump / Unit Heaters
Electric / Radiant
Other / None
-Fuel / Natural Gas / Electric / Oil / Other
RENOVATIONS YEAR
Electric / Plumbing / Heating / Roof
FIRE PROTECTION
Distance to Fire Hydrant: / Distance to Fire Hall: / Fire Alarm?
Connected to Monitoring Station?
Portable Extinguishers / Automatic Sprinkler?
OPERATIONS:
Other Occupancies in Building:
EXPOSURE (adjacent risks within 75ft – 23m)
Left: / Right: / Front:
Back:
CRIME AND BURGLARY PROTECTION
Doors - Deadbolts
Steel Bar on Openings / Breakage resistant Glass
Exterior Lighting / Windows Barred
Wire Mesh
Surveillance Camera
Concealed recording device / Watchmen/ Security Guards
Guard Dog / Fenced
Other
ALARM
Burglar Alarm
Partial / Complete / Local / Connected to Monitoring Station / Monitoring Service

LIABILITY

Total Gross Revenue:
Breakdown:
Food:
Other (ie catering): / Number of Employees: F/T:P/T:
Sublet Work (%) of Revenue: / Certificate of Insurance Obtained?
Work Outside of Canada? / Sales outside of Canada:
% of receipts for installation / repair off premises:
Who is responsible for snow removal: / Certificates of Insurance Obtained?
Are all employees covered by Workmen’s Comp?
ADDITIONAL INFORMAITON

Please complete all questions.

  1. GENERAL INFORMATION
  1. Style of Restaurant (mark all applicable)

Fast Food Family Style Bar/Pub Take-out Delivery

White Table Cloth

  1. Time in business for Restaurant

Startup 0-3 yrs 3-5 yrs 5-10 yrs 10+ yrs

  1. Hours of business
  1. Gross receipts

Food $ Liquor $ Deliveries $

% % %

Catering $ Other $

% %

  1. No. of Employees No. who serve liquor

B. MANAGEMENT

  1. Has the restaurant been in its present ownership at least 3 years? Yes No
  1. Prior restaurant experience by present owner Yes No

If so, please advise details:

  1. Does the owner manage the operations themself? Yes No

If not, how long as present manager held the position:

  1. Does the restauarnt belong to a trade association, the local better business bureau or to a franchise? Yes No
  1. Are the premises well maintained with good housekeeping? Yes No
  1. Has the restaurant ever failed a public health inspection? Yes No
  1. Does the restaurant have monthly pest control with a licensed contractor? Yes No
  1. FINANCES
  1. Is the location well-travelled and with adequate parking facilities nearby? Yes No
  1. Is there more than one mortgage, chattel mortgage, debenture or similar debt against the Restaurant?

Yes No

  1. Has the restaurant (present or prior ownership) ever experienced financial difficulties such as bankruptcy? Yes No

If so, please advise details

  1. COOKING EQUIPMENT
  1. Is all cooking equipment (except hot plates and microwave ovens) beneath –
  1. A proprietary steel canopy with a minimum 150 millimetre (6-inch) overhang on all sides that are not immediately adjacent to walls?

Yes No

  1. Steel ducts with a minimum 460 millimetre (18 inch) clearance from combustible partitions and venting directly to the outside?

Yes No

  1. A C.S.A. approved exhaust fan providing not less than 460 metres (1500 feet) per minute air velocity?

Yes No

  1. A U.L. (UL 300) or U.L.C. (ULC 1,254.60) approved wet chemical fixed automatic fire extinguishing system?

Yes No

  1. Is the canopy-duct assembly fitted with either non-combustible grease filters or with a proprietary grease extractor of the water wash or centrifugal force type? Yes No
  1. Are all deep-fat fryers equipped with an automatic power shut-off which operates when the fat temperature reaches 246°C (475°F)? Yes No
  1. Is at least one portable “Class K” wet chemical fire extinguisher or a non-combustible fire blanket located in an accesible position within 9 metres (30 feet) of the equipment? Yes No
  1. Are grease filters cleaned at least twice each week and the canopy at least once every other week?

Yes No

  1. Does the restaurant have a contract with a recognized cleaning company to remove grease from the canopy and ducts at least once every 6 months? Yes No
  1. Does the restaurant have a contract with a qualified organization for the inspection and servicing of the automatic fire extinguishing at least once every 6 months? Yes No
  1. PREMISES LIABILITY
  1. Exits:Number Well marked and litYes No
  1. Does the facility have a back-up lighting system?Yes No
  1. Washrooms:Located on: 1st floor 2nd floor Lower Floor
  1. Parking lots:No. of spaces Well lit?Yes No
  1. Describe any entertainment you have and/or plan to provide (other then incidental background music)?
  1. Any pyrotechnicsYes No
  1. Does the establishment have a dance floor?Yes No
  1. If a dance floor is provided, does it have a non-slip surface and is it at the same level as the surrounding floor?

Yes No Not applicable

  1. Does the establishment have:
  2. Pool tablesYes No If Yes, specify number:
  3. Shuffleboard tablesYes No If Yes, specify number:
  4. Dart boardsYes No If Yes, specify number:
  5. Video lottery terminalsYes No If Yes, specify number:
  6. Video machinesYes No If Yes, specify number:
  1. Are any other recreational activities available to patrons?Yes No If Yes, what?
  2. Does the establishment lease or loan the premises to others?Yes No
  1. If Yes, describe type of functions:
  1. Does the establishment provide the service of any staff for these functions? Yes No
  1. Attach a copy of contract form used for rental of the premises to others.

COVERAGES REQUESTED

Coverage / Deductible / Co-ins. / Limit
PROPERTY
Building
Equipment
Stock
Tenants Improvements
Business Interruption
-Profits – Actual Loss Sustained
-Rents/ Rental Value
Signs
Accounts Receivable
Valuable Papers
Consequential Loss
Sewer Back up
Flood
Quake
Contractors Equipment Floater (Schedule attached?)
Tools (Schedule attached?)
EQUIPMENT BREAKDOWN
CRIME
Employee Dishonesty
Loss Inside
Loss Outside
Money Orders and Counterfeit Paper
Depositors Forgery
LIABILITY
Personal Injury and Property Damage
Products/Completed Operations Hazard
Medical Expenses
Tenant’s Legal Liability
Non-Owned Automobile
OTHER COVERAGES