Applicant Information
Full Name of Business
Address of applicant		City
State		Zip Code
Mailing Address (if same, leave fields blank)		City		State		Zip Code
Owners First Name (Principal)		Owners Last Name
Owners Address		City		State		Zip Code
Home Phone #		Business Phone #
Current Insurance Information
Policy effective date?		Current company?		Current Premium?
Business Information
Applicant is a: (pick one)	Corporation Partnership Individual Other	If other, please specify:
Applicant is a: (pick one)	Resturaunt Diner Tavern Night Club Banquet Hall Other	If other, please specify:
# of years at current location		# of years in resturaunt business		If less than 3 years at this location, please list previous experience:
Building Owners First Name		Owners Last Name
Owners Address		City		State		Zip Code
Include building owner as Named Insured as Interest may appear?	Yes No
Financial Information
Is owner or corporation now or ever involved in: (Please answer all of the below Y/N)
Bankruptcy?	No Yes	Foreclosures?	No Yes	Tax Liens?	No Yes
Business Failures?	No Yes	Any Litigations?	No Yes	If Yes to any of the above, please explain:
Additional Interests
Mortgage and Address	No Yes	If yes, explain or give any notes:
Additional Insureds	No Yes	If yes, explain or give any notes:
Loss Payees	No Yes	If yes, explain or give any notes:
Property Section
Building limit		Co-Ins%		ACV
R/C		Deductible
Contents limit		Co-Ins%		ACV
R/C		Deductible
Business Income Limit		Contribution or Co-Ins%		Decutbile		Business Income ALS. NOTE: If "Yes", Business Income worksheet MUST be completed. If worksheet is not completed and signed, ALS will not be quoted.	Yes No
Cause of loss: Basic		Cause of loss: Special		Cause of loss: Special with Theft on contents only
Business Income with Extra Expense.	Yes No
Loss of Rents Limit		Co-Ins%		Cause of Loss		Deductible
Sign Limit		Type		Wording		Deductible
Glass Coverage Needed?	Yes No	If "Yes", please schedule
Crime Coverage Form C Limit		Deductible		Employee Dishonesty Limit		Deductible
Other Property Coverage
Liability Section
General Liability Limit		Aggregate		Liquor Liability Limit		Aggregate
Reciepts: Food		Reciepts: Liquor		Reciepts: Other		Reciepts: Total
Sq. Foot: Total Bldg		Sq. Foot: Restaurant		Sq. Foot: Apartments		# of Apartments
Off Premise Parking	Yes No	If "Yes", please list address and square footage.
On or Off premise catering/banquet	Yes No	If "Yes", % of total Reciepts		Describe Catering Operation
Lodging Operations other than apartments	Yes No	If "Yes", please describe.		Any other On or Off premise exposures NOT listed abobe	Yes No	If "Yes", please describe.
Non-Owned Automobile	Yes No	If "Yes", please describe. NOTE: Hired car not offered
Valet Parking	Yes No	If "Yes", is Garage Keeper Liability required?	Yes No	If "Yes": Limit		If "Yes": Deductible
Claims Section
List ALL Claims for each section for the past 5 years, by year. If none, NONE must be stated, by year.
Property Claims
General Liability Claims
Liquor Liability Claims
Umbrella Claims
Umbrella Section
Limit Requested		Business Auto Center		Policy #		Premium
Total # of vehicles		# Private Passenger		# Commercial		Limit
Employers Liability Carrier		Policy #		Limit
Operations Section
Is Applicant open now?	Yes No	If "No", please explain.
Hours of Operation: Open From:		To:		# of Days per week
Is Applicant a seasonal operation?	Yes No	If "Yes", please explain.		Distance to Ocean or closest body of water:
Physical Plant Section
Age of Building		Construction		# of stories
Age of: Wiring		Age of: Plumbing		Age of: Heating		Age of: Roofing
Smoke Detectors?	Yes No	If "Yes", electric?		Battery Powered?	Yes No
Fire Alarm	Yes No	If "Yes", type of alarm.		Burglar Alarm?	Yes No	If "Yes", type of alarm.
Sprinkler System	Yes No	If "Yes", type of system.		If "Yes", age of system.