Restaurant Insurance Quote Form For the fastest and most accurate restaurant insurance quote, please provide as much information possible in the form below. This information will be kept confidential and will be used for quote purposes ONLY!

General Information
Name of Business:
Contact Name:
Mailing Address:
City:	State:   Zip:
Business Phone:	Fax:
Best Time To Call:	AM   PM
Contact Email Address:

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   $

Contents (90%) Replacement Value   Special Form   $

Business Income   %   $

Per Claim Deductible     $1,000

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:	Sprinkler       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
		Y N	Y N	Y N	Y N
Building Condition		Housekeeping		# of Stories	Building Code Violations
		ExcellentGoodPoor			Y N
What is Right Exposure		What is Left Exposure		What is Rear Exposure
Free Standing		Other Occupancies		Distance to Nearest Fire Hydrant
Y N
If adjacent business is a restaurant, does it have automatic extinguishing devices?			Is any portion of the building vacant, unoccupied, or seasonal? (If yes, explain)
Y N			Y N
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?
Y N	Y N			Y N
Exhaust filters are cleaned	Is there a professional flue cleaning service used on quarterly contract?
DailyWeeklyMonthlyOther	Y N     By:     Phone Number:
Deep Fat Fryers	Automatic Shut Off	High Limit Switch	Non-Slip Floors	Other Kitchen Safety Precautions
NoneGasElectricBoth	Y N	Y N	Y N

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

Underwriting Information
CRIME
Safe Class	Type of Locks	Maximum Cash in Register	Check Cashing
			Y N
Alarm	# of Alarms	Motion Detectors
NoneLocalCentral		Y N     How often checked:
Name of Alarm Company		Any weapons on premises
Ph#:		Y N     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
		Y N	Y N	Y N	Y N
Hours Open		Days Closed	# of Employees	Estimated Annual Payroll	Neighborhood
From  to					StableDeclining
Ever suffered earthquake damage	Type of food served on premises		Flaming Drinks	Happy Hours	Written policy for serving minors/ intoxicated patrons
Y N			Y N	Y N	Y N
Exits properly marked	Alternate Access	Security Guards	Parking areas adequately lit/maintained	Separate cigarette butt containers	Designated Smoking Areas
Y N	Y N	Y N	Y N	Y N	Y N
Dart Boards	Mechanical Devices	Prior problems requiring police		Any Liquor Violations
Y N	Y N	Y N If yes:		Y N If yes:

Loss History
Current / Previous Insurance Company:
Policy Number:	Expires:
Has any carrier cancelled or refused insurance to this applicant:	Y N     If yes:
Please describe any losses during the past three (3) years
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, please enter them here.

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