RESTAURANT WORKSHEET

First Name: Last Name: Business Name: Mailing Address: Mailing City: Mailing State: Select...AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming 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: 1 2  Construction Type: Frame Masonry Veneer Masonry Superior   Roof Type: Tile Slate Metal Woodshake Composite Material   Roof Updated: yes no  If Yes, Year Roof was Updated: Protection Distance: 1000 ft or less to a hydrant & 5 mi or less to a fire station Over 1000 ft to a hydrant & 5 mi or less to a fire station Over 5 & up to 10 mi to a fire station Over 10 mi to a fire station  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: None Local Central  Fire Alarm: None Local  Fire Extinguisher: yesno Deadbolts On All Doors? yesno Circuit Breakers: yesno Electrical Updated: Yes, Updated No  Heating - Air Conditioning, Thermostatically Controlled?: yesno  Heating - Air Conditioning, Central? yesno Plumbing Updated: yesno If Yes, Year Plumbing was Updated: Interior Automatic Fire Sprinklers:  None Partial Full  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: Weekly Monthly  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:    none one two three four five   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: $100,000 $300,000 $500,000 $1,000,000  Policy Deductible: 100 250 500 750 1000 2500 5000  Questions or Comments to help the Agent: Please press the Submit Button ONCE. Then wait for online confirmation of your request. Thank you for your interest.