Header
Applications
Restaurant Online Application Quote Process
 
* 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.

 

 

© 2011 All Rights Reserved- Hospitality Insurance Providers is a subsidiary of Affiliated Insurance Agency, Inc.
Site design and maintained by HolleHock Designs, Inc.