Restaurant Online Application

Corporation: Name & DBA
Contact Person:
Email Address:
Physical Address:
Mailing Address:
Phone #:
Fax #:
Effective Date/Renewal Date:
# of years in business:
Food Sales:
Alcohol Sales:
Cover Sales:
Misc. Sales:
Building Information: Sq. Feet of Building:
Number of Stories:
Basement?	Yes No
Adjacent Tenants:	Yes No
Building Construction Type & Age:
Roof Construction Type & Age:
Updates/years:
Wiring:
Roofing:
Plumbing:
Heating:
Located within city limits?	Yes No
Distance to shoreline?
Cooking: Yes or No	Yes No
If yes, ansul system:
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?
How often?
Auto fire extinguishing system?	Yes No
Security System:	Yes No
Name of Monitoring Co:
How many fire extinguishers:
Sprinklered?	Yes No
Distance from fire hydrant?
Distance from Fire Station?
Operations
Hours of Operation:	From: To:
	M T W Th F Sat Sun
Is there entertainment?	Yes No
What type & how often?
How many video games, pool tables, darts, etc?
Dancing:	Yes No
If yes, Sq. feet of dance floor
Coverage
Liability Amount:
Liquor Liab:
Assault & Battery:	Yes No
Non-owned/hired auto:	Yes No
Building Amount:
Contents Amount:
Tenant Improvements:
Loss of Income:
Do you currently have insurance?	Yes No
With Who?
Present Premium:
Policy #:
Loss Information (Prior 5 years; dates & amounts:
Loss Payee Info:
Additional Insured Info:
General Information
Any policy declined or cancelled 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 insureds control? Yes No
If yes, square footage:
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 clientelle?
What is the seating capacity?
When is Happy Hour? Ladies Night?
What type of Certified training for bartenders and servers?