Tel. 1-800-462-2604

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Restaurant Worksheet
Business Name:
Name:
Property Address:
Property City:
Property State:
Property Zip Code:
Phone Number:
Fax Number:
E-Mail Address:
Property Information
Total Sq. ft.:
Square Footage Of The Customer Area:
How Many Stories:
Construction Type:
Roof Type:  
Roof Updated: Yes No  
If Yes, Year Roof was Updated:
Protection Distance:
Are There Smoke Detectors At This Location? Yes No
Smoke Alarm: Yes No
Theft Alarm:
Fire Alarm:
Fire Extinguisher: Yes No
Deadbolts On All Doors? Yes No
Circuit Breakers: Yes No
Electrical Updated:
Heating - Air Conditioning Yes No
Heating - Air Conditioning, Central? Yes No
Plumbing Updated: Yes No
If Yes, Year Plumbing was Updated:
Interior Automatic Fire Sprinklers: 
How many parking spaces are under your control?
Underwriting Information
Please Describe the Nature of Your Business
Number of Owners:
Number of Employees:
Payroll of Owners:
Payroll of Employees:
Total Annual Gross Receipts:
Total Annual HARD LIQUOR Receipts:
Total Annual BEER & WINE Receipts:
Total Annual FOOD Gross Receipts:
License Type:
Years of Experience:
How Many Years Have You Operated This Business:

Entertainment Details
Is There Entertainment? Yes No
If Yes, Describe:
Is There LIVE Music? Yes No
If Yes, Indicate Size of the Dance Floor and Nights Per Week:
Any Pool Tables? Yes No
Any Bouncers, Doormen, ID Checkers, Armed Guard, Security Guards? Yes No
If Yes, How Many Of Each, List Their Job Duties & Are They Your Employees:

Miscelaneous Information
Losses-Claims in the last 5 years:   
If Yes, date, amount paid and description of each loss-claim
Current Insurance Company:
Current Renewal Date:
Has Insurance Ever Been Cancelled? Yes No
If Yes, Describe:
Have You Ever Had Regulatory Violations or Citations? Yes No
If Yes, Describe:

Coverage Request
Building Coverage:
Other Structures Coverage:
Business Contents Coverage:
Loss of Use Coverage:
Liability Limits Requested:
Policy Deductible:
Comments :