Restaurant Supplemental Questionnaire

It is mandatory in order to obtain a quote that all questions be answered and the form included with application. 
 
Applicant:
Location:
DESCRIPTION OF OPERATIONS:
RECEIPTS:
Food$:
Liquor $
Other:
Type of Restaurant
Business Hours
From:
To:
Business Days
From:
To:
Total Area:
Customer Area:
Kitchen Area:
Banquet Area:
Outside Patio Area:
Bar/Lounge Area:
Seating Capacity:
Make of Automatic Suppression System:
Frequency of Service:
Does System have Automatic fuel cut-off?
YesNo
Do Deep Fryers have cut off controls?
YesNo
Does the Restaurant or Lounge have a dance floor?
YesNo
If Yes, What is the total S.Q.FT
Does applicant sub-let any operations?
YesNo
If Yes Explain
Is restaurant operated by hotel owner?
YesNo
If No Explain
Has applicant ever filed for bankruptcy?
YesN0
If Yes Explain
Has any business other than a restaurant been at this location?
YesNo
Does applicant maintain parking areas?
YesNo
Does applicant provide Valet Parking services?
YesNo
If Yes Explain
If valet parking is contracted is proof if insurance provided?
YesNo
Do all drivers have valid driver's license?
YesNo
Is 'Valet Parking Lot' fenced and well lit?
YesNo
Are all drivers over 21 years old?
YesNo
Is there table-side cooking or flambé?
YesNo
Does restaurant provide catering services?
YesNo
If Yes Explain
Are employees references checked prior to hiring?
YesNo
Are employees references checked prior to hiring?
YesNo
If Yes Explain
Do the premises have more than one exit & are exits well lit?
YesNo
Sponsorship of any sports, special events?
YesNo
If Yes Explain
Has the restaurant been cited for any health code violations?
Yes No
If Yes Explain
LIQUOR EXPOSURE:
Type of Liquor License?
Length of time Applicant has had License?
Expiration Date of Liquor License?
(Check as Applicable)
Beer/Wine - Public Premises
General Liquor - Public Premises
Beer/Wine - Eating Establishment
General Liquor - Eating Establishment
 
Entertainment (Check as Applicable)
Juke Box
Dancing 2-3 nights
Dancing 4-7 nights
Pool Table
Card Table
Dart Board
Combo
 
Type of Music (Check as Applicable)
Disco
Country Western
Hard Rock
Top 40's
Music Band
 
Other Comments:
 
NOTE:  Before transmitting this form via our website, please print a copy for your records and for the insured's signature.  We require that the insured sign this form and for the signed copy to be faxed to our office prior to binding.  Please note that coverage can't be bound or amended via this website.  You must receive a binder or written confirmation from our office for coverage to be bound.
Submit