Restaurant Quote
Fields marked (*) are mandatory.

General Information
Name of Buisness*
Contact Name*
Mailing Address*
City*
State*
Zip*
Business Phone*
Fax
Best time to Call
Contact Email Address*
Referred By*

About Your Business
Location Address (if different)
City
State
Zip
Type Of Risk
Restaurant
Tavern
Fast Food
Bar
Other
Applicant Is
Individual
Corporation
Partnership
Joint Venture
Other
MortGagee
MortGagee Interest
Additional Insured
Additional Insured Interest
Effective Date Requested
Expiration Date

Coverages

Property
Building (90%) AC
Broad Form
Value ($)
Contents (90%) Replacement Value
Special Form
Value ($)
Business Income
(%)
Value ($)
Per Claim Deductible

Liability
General Aggregate ($)
Products/Completed Operations Aggregate ($)
Per Occurrence ($)
Medical Payments ($)
Fire Damage ($)
Liquor Liability ($)

Optional Coverages
Sign (Limits In/Out, $)
Glass (Square Footage, $)
Money/Secs (Limits In/Out, $)
Food Spoilage (Limits In/Out, $)
Other

Rating Information
Construction Type
Fire/Protection
Spinkler
Smoke Detector
Fire Extinguisher
Square Footage
Total
Customer
Food Receipts
($)
Liquor Receipts ($)

Underwriting Information

Property
Building Information
Age
When Rewired
Electrical in Conduit*
Circuit Breakers*
Fuse Box*
Plumbing up to Code*
Building Condition
Housekeeping
# of Stories
Building Code Violation*
What is Right Exposure
What is Left Exposure
What is Rear Exposure
Free Standing*
Other Occupancies
Distance to Near Fire Hydrant
If adjacent business is a resturant, does it have
automatic exinguishing devices?
Is any portion of the building vacant, unoccupied,
or seasonal
If Yes, Explain
Kitchen Information
Grease Cooking*
Are ducts, hoods, grease filters and surface
cooking areas (including deep fat fryers) protected
by a U.S. listed automatic fire extinguishing system?*
Is such a system professionally inspected and
serviced every 6 months?*
Exhaust filters are cleaned
Is there a professional flue cleaning service used
on quarterly contract?*
By
Phone number
Deep Fat Fryers
Automatic Shut Off
High Limit Switch
Non-Slip Floors
Other Kitchen Safety Precautions

Underwriting Information
LIABILITY
Entertainment
Live Entertainment
# of Players
Kind of Music
How Many Nights
Dancing
Disco
# of Pool Tables
# of Game Machines

Underwriting Information
CRIME
Safe Class
Type of Locks
Maximum Cash in Register
Check Cashing
Alarm
# of Alarms
Motion Detectors
If Yes How often checked
Name of Alarm Company
Ph# of Alarm Company
Any weapons on premises
If yes, explain

Underwriting Information
GENERAL
How long at this location
How long in this type business
Operated by Owner
Table Service
Self Service
Any Delivery
Hours Open (From - To)
Days Closed
# of Employees
Estimated Annual Payroll
Neighborhood
Ever suffered earthquake damage
Type of food served on premises
Flaming Drinks
Happy Hours
Written policy for serving minors/intoxicated patrons
Exits properly marked
Alternate Access
Security Guards
Parking areas adequately lit/maintained
Separate cigarette butt containers
Designated Smoking Are as
Dart Boards
Mechanical Devices
Prior problems requiring police
If Yes
Any Liquor Violations
If Yes
Loss History
Current / Previous Insurance Company:
Policy Number
Expires
Has any carrier cancelled or refused insurance to this applicant:
If yes
Please describe any losses during the past three (3) years
Date of Loss:
Amount:
Description of Loss:
Date of Loss:
Amount:
Description of Loss:
Date of Loss:
Amount:
Description of Loss:
Date of Loss:
Amount:
Description of Loss:
Date of Loss:
Amount:
Description of Loss:
Additional Comments
Please give any additional comments you feel
appropriate for this quotation. If you have
additional information where there was not
enough space, plea
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