RESTAURANT INSURANCE QUOTE

Cooper, Simms, Nelson, & Mosley World Wide Web Site Online Insurance Application


		IMPORTANT NOTICE: Please note that no coverage can be bound using e-Mail, the Internet, or by leaving a voice mail message. All requests must b conducted through our agency with signed applications.


Toll Free: 1.877.644.2766 Providing Insurance Since 1934


RESTAURANT INSURANCE QUOTE		We would like to provide you with a free, no-obligation Restaurant insurance quote. Please provide as much information possible for the most accurate quote. 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

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
					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?
	Y N By: Phone Number:
Deep Fat Fryers	Automatic Shut Off	High Limit Switch	Non-Slip Floors	Other Kitchen Safety Precautions
	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
		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
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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