RESTAURANT WORKSHEET

 

First Name:

Last Name:

Business Name:

Mailing Address:

Mailing City:

Mailing State:

Mailing Zip Code:

Phone Number:

Fax Number:

E-Mail Address:

PROPERTY INFORMATION

 

Property Address:

 

Property City:

Property State:

California

Property Zip Code:

Property County:

Total Square Footage of the Building Your Business Is In:

Square Footage Of Your Business Only:

Square Footage Of The Customer Area:

How Many Stories:

Construction Type:

 

Roof Type:

 

Roof Updated:

yes no 

If Yes, Year Roof was Updated:

Protection Distance:

Is The Business In A Brush Area?

yesno 

Is There Storage More Than 1500 Sq Ft?

yesno 

Are There Smoke Detectors At This Location?

yesno

Smoke Alarm:

yesno

Theft Alarm:

Fire Alarm:

Fire Extinguisher:

yesno

Deadbolts On All Doors?

yesno

Circuit Breakers:

yesno

Electrical Updated:

Heating - Air Conditioning, Thermostatically Controlled?:

yesno 

Heating - Air Conditioning, Central?

yesno

Plumbing Updated:

yesno

If Yes, Year Plumbing was Updated:

Interior Automatic Fire Sprinklers: 

Is The Parking Lot Under Your Protection?

yesno

UNDERWRITING INFORMATION

 

Please Describe the Nature of Your Business and Any Unusual Exposures:

 

Number of Owners:

Number of Employees:

Payroll of Owners:

Payroll of Employees:

Total Annual Gross Receipts:

Total Annual HARD LIQUOR Receipts:

Total Annual BEER & WINE Receipts:

Total Annual FOOD Gross Receipts:

Business License Number:

License Type:

Years of Experience:

How Many Years Have You Operated This Business:

Is This Business Open 24 Hours A Day?

yesno

Is there Filing Of Propane Tanks? 

yesno 

ENTERTAINMENT INFORMATION

 

Is There Entertainment?

 

yesno

If Yes, Describe:

Is There LIVE Music?

yesno

If Yes, Indicate Size of the Dance Floor and Nights Per Week:

Any Coin Operated Amusement Devices?

yesno

If Yes, Describe:

Any Pool Tables?

yesno

If Yes, How Many And Are They Coin Operated:

Any Bouncers, Doormen, ID Checkers, Armed Guard, Security Guards?

yesno

If Yes, How Many Of Each, List Their Job Duties & Are They Your Employees:

Any Contests or Exhibitions?

yesno

If Yes, Describe Events:

Any Audience Participation Events?

yesno

If Yes, Describe Events:

Do You Sponsor Any Sporting Events?

yesno

If Yes, Describe Events:

Did We Miss Any Other Type Of Entertainment, If Yes, Describe:

COOKING INFORMATION

 

Describe The Cooking Devices At Your Business:

 

Tableside Cooking?

yesno

Automatic Suppression System?

yesno

If Yes, Do They Protect All Hoods, Ducts & Griddles?

yesno

Any Deep Frying (Food)?

yesno

If Yes, Is There A High Limit Shutoff?

yesno

Do You Have An Outside Cleaning Service For The Hoods & Duct System?

yesno

How Often Are Hood & Duct Cleaned:

Is There Any Manufacturing, Mixing, Re-Labeling or Repackaging of Products?

yesno

Any Delivery Service?

yesno

Any Catering Service?

yesno

MISC INFORMATION

 

Losses-Claims in the last 5 years: 

 

 

If yes, date, amount paid and description of each loss-claim

Current Insurance Company:

Current Renewal Date:

Has Insurance Ever Been Cancelled?

yesno

If Yes, Describe:

Have You Ever Had Regulatory Violations or Citations?

yesno

If Yes, Describe:

Are Employees Trained On How To Handle Minors or Intoxicated Customers?

yesno

If Yes, Describe:

COVERAGE INFORMATION

 

Building Coverage:

 

Other Structures Coverage:

Business Contents Coverage:

Loss of Use Coverage:

Liability Limits Requested:

Policy Deductible:

Questions or Comments
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Thank you for your interest.