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:

Premises Information Section

Location Number: 1 2 3 4 5 Location Address: City: State: AL AK CA CT DC NJ NM NY PA Zip:

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
		Excellent Good Poor			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?
Daily Weekly Monthly Other	Y  N     By:     Phone Number:
Deep Fat Fryers	Automatic Shut Off	High Limit Switch	Non-Slip Floors	Other Kitchen Safety Precautions
None Gas Electric Both	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
None Local Central		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					Stable Declining
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

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