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: Website 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.Isbuilding 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 negligent 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 insurance as follows:
Accounts Receivable—$25,000Computer Equipment—$25,000Outside Signs—$10,000
Spoilage—$25,000Valuable Papers—$25,000Fine Arts—$15,000
Money & Securities—$25,000Employee Dishonesty—$10,000Property of Others—$10,000
Back-up of Sewer & Drains—$15,000Outdoor Property—$10,000Property 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:
29.Any off premises catering?...... Yes No
30.Is there a UL certified automaticsuppression 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 ofLiability / 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
Describe the insurable interest:
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
If yes, explain:
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 threeyears (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 suspensions, 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 including 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 guidelines. 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 information 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 information 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 payable 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 insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony 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 subject 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.