Hospitality Insurance Providers

www.hospitalityinsuranceproviders.com

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Applications

* REQUIRED

Corporation
*Name and DBA
*Contact Person
*Address
*City
*State
*Zip
E-mail Address	name@address.com
*Phone Number (area code)	(xxx) xxx-xxxx
Best time to call
Any comments to add?
Effective Date	MM/DD/YYYY
Renewal Date
Number of Years in Business	years
	If under 3 years, indicate other experience in the hospitality industry
Sales
Food Receipts
Alcohol Receipts
Cover Receipts
Labor
Gross annual payroll (pre-tax)
Number of full time employees
Number of part time employees
Payroll for salaried employees (if any)
Building Information
Sq. Feet of Building		Number of stories
Basement?	(yes/no)	Number of Adjacent Tenants
Building Construction Type		Building Age
Roof Construction Type		Roof Age
Updates/Year	Wiring: Roofing: Plumbing: Heating:
Located in City Limits	(yes/no)	Distance to Shoreline?	miles
Cooking
Cooking?	(yes/no) If NO, please continue past this section to the next section.
If yes, Ansul System?	(yes/no)
Covers:	All Foods? (yes/no)
	Deep Fat Fryers (yes/no)
	Open Flames (yes/no)
Service Contract for cleaning?	(yes/no)
Cleaning Company Name
Date Last Cleaned	(mm/dd/yyyy)
How Often
Auto Fire Extinguishing System	(yes/no)	How Many Fire Extinguishers
Security System	(yes/no)	Name of Monitoring Company
Sprinklers	(yes/no)	Distance from Fire Hydrant
		Distance from Fire Station
Operations
Hours of Operation	Please list time and days if there are different times for different days
Is there Entertainment?	(yes/no)
What type and how often
How many of the following	Video Games Pool Tables Dart Boards
Dancing	(yes/no)	If Yes, what is the square footage of the dance floor?	sq. ft.
Coverage and Amounts
Liability Amount		Liquor Liability
Assault & Battery		Non-owned/hired Auto
Building Amount		Contents Amount
Tenant Improvements		Loss of Income
Do you currently a have Insurance	(yes/no)	If so, with whom
Present Premium		Policy Number
Loss Information
Additional Insured Information
General Information
Any policy declined or canceled during the prior three years?	(yes/no)
Any bankruptcies, tax or credit liens against the applicant in the past five years?	(yes/no)
Is parking lot under insured's control?	(yes/no)	If yes, sq. footage	sq. ft.
Is valet parking provided	(yes/no)	If yes, employees or service?
Has there been any incidents involving Assault & Battery in the past three years?	(yes/no)
Number of bartenders/servers	#full-time #part-time
Do you have a formal written safety program?	(yes/no)
Average age of clientele?
What is the seating capacity?
When is Happy Hour?
When is "Lady's Night"?
What type of Certified training for bartenders and servers?

Quotes are based on information provided, which will be verified before acceptance.
Acceptance is based upon your continuing qualification. Individual savings may vary.
Additional information may be required to complete accurate quote.
You will NOT automatically be covered by insurance by simply submitting a request for insurance quote or applying online.
Your agent will let you know, if accepted, when your insurance coverage begins.

Definitions of Coverages