Place an Order
1) Business Info
a. Name of Business Entity
b. Name of Restaurant if different
c. Street Address
d. City
e. State
--- Choose a State ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
D.C.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
f. Zip code
g. Form of business (C Corp, LLC, S Corp, etc.)
h. Years in the Restaurant Business:
i. Years at this location:
j. Federal Employer ID:
2) Type of Establishment
Fine Dining Restaurant (Average Entrée Greater than $15.00)
Family Restaurant
Fast Food (No Table Service)
Bar or Tavern
Night Club
Banquet Facility
Caterer
Coffee Shop
Prepared Meals To Go
Delicatessens
Sandwich Shop
Pizza Restaurant
Donut Shop
Bakeries
Ice Cream and Yogurt Stores
Juice Bars
Guest House
3) Operations
Franchise
Non-franchise
4) Contact Info
a. Contact Name
b. Contact Responsibility
c. Phone Number
d. Best time to Call
e. Email
f. Web Site
5) Policy Information
a. Workers Compensation Insurer
b. Workers Compensation Policy Anniversary Date
c. Property and Liability Insurer
d. Property and Liability Policy Anniversary Date
6) Building
a. Year Built:
b. Are you the owner or tenant?
Owner
Tenant
c. What is the building’s construction:
Wood Frame
Masonry
Steel
d. What is total square footage of building?
e. What is square footage of space restaurant occupies?
f. Distance to nearest fire hydrant:
Less than 500 ft
500 ft to 1,000 ft
Greater than 1000 ft
g. Distance to nearest fire station:
Less than 1 mile
1 mile to 3 miles
Greater than 3 miles
h. What are the other occupancies if any?
Apartments
Hotel/Motel
Office
Retail Stores
Other
i. Is there a Central Station Burglar Alarm?
Yes
No
j. Is there a Central Station Fire Alarm?
Yes
No
k. Is there any Fire Protection system in the building (other than over the stove) such as sprinklers, standpipes, CO2/Chemical Systems?
Yes
No
7) Business Property Values
a. What is insured value of building?
b. What is the value of all improvements and betterments to the property interior?
c. What is the value of all business personal property?
d. What is the average value of all food stocks and liquor?
8) Seating Capacity
a. What is your total seating capacity?
b. What is your seating capacity at the bar?
9) Kitchen Fire Protection
a. Is there a UL approved automatic extinguishing system under maintenance contract?
Yes
No
b. Is it Wet or Dry?
Wet
Dry
c. Is there a grease-cleaning program in place for filters and equipment?
Yes
No
d. Is there a hood and duct cleaning program in place?
Yes
No
e. Is there a BC Extinguisher in Kitchen
Yes
No
f. Is there automatic gas or electric shut-offs for cooking?
Yes
No
10) Food and Liquor Operations
a. What are your gross receipts?
b. What are your hours of operation:
c. Do You Deliver?
Yes
No
d. Any on or off premises catering?
Yes
No
e. Do you serve Liquor?
Yes
No
i. What is liquor as % of total Receipts
ii. Are employees given any formal TIPS or similar alcohol server training course?
Yes
No
f. Do you have entertainment?
Yes
No
i. What type
Karaoke
Rock Band
Pianist
Adult
Other
ii. What nights
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
iii. Do you employ Bouncers?
Yes
No
iv. Do you charge a cover?
Yes
No
11) Auto Liability
a. Does the business own or lease autos?
Own
Lease
b. Are personal autos of employees or management used?
Yes
No
12) Employees
a. Number of full time employees:
b. Number of part time employees:
c. Total Payroll of full time employees:
$
d. Total Payroll of part-time employees:
$
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