Account Name: / Policy Number:
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EXPLAIN ANY ANSWERS THAT VARY BY LOCATION IN THE NOTES SECTION ON THE SECOND PAGE
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REQUIRED FOR ALLDate premises inspected by agent
Experience at location / years
List hours of operation / 24 hr
am - pm
Seating capacity / Restaurant
Bar
Amusement devices / Yes No
If yes, explain below.
Entertainment
If yes, number of nights per week / None
Piano/Organ
Band or DJ
Dance Floor sq ft
Firearms/Weapons on premises
If yes, describe in narrative: / Yes No
Housekeeping-maintenance and repair / Excellent Average Good Poor
Has the electrical system been updated (to current building code standards) in the last 25 years? / Yes No
Year:
Have new breaker boxes and wiring been added to the system? / Yes No
Are there any permanent fixtures, equipment or coolers powered by extension cords? / Yes No
Are there any portions of the premises vacant? / Yes No
If yes, explain below.
Is catering offered?
If yes, % of gross receipts: / Yes No
%
AUTOMOBILE
Delivery
Are Certificates of Insurance obtained? / None By insured
By third party
Yes No
Valet Parking
If provided, describe key controls:
Are Certificates of Insurance obtained? / Not provided By insured By third party
Yes No
GENERAL LIABILITY
PREMISES LIABILITY
Self inspection of public areas / Yes No
Self inspection of exterior (entry, outside dining areas, parking) / Yes No
Snow and ice removal (as needed) / Yes No
Spill cleanup procedures
Assigned responsibilities
Wet floor signs utilized / Yes No
Yes No
Yes No
Food handling guidelines
Restaurant cleanliness/Personal hygiene guidelines / Yes No
Yes No
Tableside or fondue cooking / Yes No
Incidents reported within 24 hours / Yes No
Incident investigation forms are used on each incident (involving patrons or employees) / Yes No
PRODUCT LIABILITY
Any Board of Health violations during the last 36 months?
If yes, please describe: / Yes No
Are food shipments checked for quality? / Yes No
Is refrigeration maintained at <41°F?
Freezers at <20°F? / Yes No
Yes No
Is wait staff made aware of all ingredients that are potential allergens? / Yes No
Is fresh shellfish served? / Yes No
Is raw meat/seafood served? / Yes No
Appropriate disclaimers posted and on menus regarding consumption of raw or undercooked meats, poultry, seafood, shellfish, or eggs? / Yes No
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FIRE SUPPRESSION AND PREVENTION SYSTEMSAre portable fire extinguishers mounted, accessible, charged, and serviced annually? / Yes No
Number of extinguishers
Is there a UL 300 compliant Automatic Extinguishing System? / Yes No
Wet Dry
Select brand:
If other than shown, describe in narrative below. / Pyrochem Ansul
Range Guard Kidde
Other
Is there a Class K (wet chemical) fire extinguisher in all cooking areas? / Yes No
Is the fire suppression system serviced twice a year by a licensed contractor? / Yes No
Is there a contracted cleaning program established for the hood and ventilation system?
Number of times per year: / Yes No
How often are filters/screens pulled down and cleaned? / More than once per week Weekly Monthly
The following section IS required onlyIF LIQUOR IS SERVED
In the past five (5) years, has a state or local liquor authority taken disciplinary action, or has legal action been brought against the restaurant or its employees alleging liability resulting from the serving of alcohol? / Yes No
If yes, please explain in the notes section below.
Are all servers and managers required to complete TIPS or other certified alcohol awareness course?
If yes, identify the program:
When do they receive training? / Yes No
At Hire Annually
Other
Are there any security personnel, bouncers, or ID checkers?
If yes, explain in narrative: / Yes No
Does risk have “Happy Hours,” reduced drink rates, or similar promotions? / Yes No
Annual number of special events such as wedding receptions and other activities? / Please explain in the notes section below.
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NOTES: FOR ADDITIONAL INFORMATION OR EXplaNATION OF any answers that vary by locationTHE FOLLOWING SECTION IS REQUIRED FOR WORKERS COMPENSATION
WORKERS COMPENSATION PREVENTION PROGRAMS
Safety Program: / None
Written policy / Written manual
Injury &illness prevention program
Health Benefits / Health Benefits Offered / Percentage paid by employer: %
Drug Test: / None
Post-accident / Post-offer
Random
Hiring: / Written application
In-person interviews
Check references on all applicants
Check references sometimes / No reference checks
Background checks on cash handlers
Other background checks
Safety Training: / None
Informal
Documented
Checklist used / Video
Quizzes
Refresher training
Topics: / Slip and falls
Cut prevention
Safe lifting / OSHA programs
Other
Personal Protective Equipment / Use slip-resistant shoes
Use cut-resistant gloves / Use oven mitts
Slip-resistant shoes, oven mitts, and cut-resistant gloves available but not required
Safety Committees: / None
Monthly meetings
Bi-monthly meetings
Quarterly meetings
Corporate committee only / Meeting minutes documented
No documentation
Self-inspections
Training topics discussed
Accidents/near misses discussed
WORKERS COMPENSATION CONTROL PROGRAMS
Claim Program: / Claims kits on hand / 24-hour claim reporting training/communication for all managers
Designated Doctor: / None
Designated doctor / Doctor panel set-up
Store doctor/panel poster
Return to Work / None
Offers modified duty only
Offers transitional duty / Written policy & procedure
Will work with claims to bring back injured workers
Accident Investigations / None
Informal
Written policy & procedures
Investigations by restaurant managers / Investigation documented
Corrective or preventive measures taken
Reviewed by safety committee
Risk Participation / Owners on premises and involved in the daily operation of the business / Limited ownership / corporate involvement
No ownership / corporate involvement
Total # of employees per location:
Maximum # of employees at any one time per location (excluding shift change):
Management W/C Attitude & Commitment / Excellent Good Average Poor
Narrative:
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