Restaurant Supplemental Questionnaire

TELL US ABOUT YOUR BUSINESS:

Named Insured Entity: *

DBA Name: *

FEIN # *

What Year Did The Business Open? *

Classification Of Business (select ALL relevant): *

Mailing Address Only: *

Website *

Contact Person *

Phone Number *

Email *

Current Insurance Information (who is the current insurance carrier?, what are the effective/expiration dates?): *

Please Upload Current Insurance Declaration Pages (used to analyze current coverage, limits, exclusions and premium):

Drag & Drop Files, Choose Files to Upload

Has The Business Had Continuous Coverage For Past 3 Years No Lapses? *

Yes
No

Is This A Franchise? *

Yes
No

Is This A Seasonal Risk? *

Yes
No

If Yes, What Months & Total Days Vacant? *

Liquor License? *

Yes
No

Liquor License Type & Number: *

Is There A Full Bar With Seating? *

Yes
No

Is BYOB Permitted? *

Yes
No

LOCATION #1 PROPERTY DETAILS - If there are additional locations, please submit a separate property section form for each.

Physical Location Address: *

Days & Hours Of Operation: *

Amount Of Business Personal Property $ Coverage Limit Needed *

(ie kitchen equipment, furniture, utensils, inventory, supplies etc. )

Amount Of Betterments & Improvements $ Coverage Limit Needed *

(ie renovations, built in bar/counters/both permanently installed lighting and sound systems, custom flooring/tile/wall finishes, built in refrigerators/freezers, plumbing/electrical upgrades)

Does Business Own The Building? *

Yes
No

If Yes, Amount Of Building Coverage Limit Needed ($): *

Building Construction Type (All Masonry, Wood/Masonry, All Wood): *

# Of Stories: *

Square Foot Of Building: *

Square Foot Occupied By Business: *

Square Foot Open To Public/Customers *

Last Year Of Roof Update: *

Last Year Of Electrical Wiring Update (must be circuit breakers): *

Last Year Of Plumbing Update: *

Last Year Of Heating Update: *

LIABILITY EXPOSURES

Total Annual Sales: *

Total Food Sales: *

Total Liquor Sales: *

Total Catering Sales (if any): *

Total Persons Seating Capacity: *

Total # Of Tables *

Total # Of Bar Seats *

Does Business Use Food Delivery Apps? *

Yes
No

Does Business Deliver Own Food In Company or Employee Owned Vehicles with Employee Drivers? *

Yes
No

Do You Offer Specific Entertainment: Dance Floor, Bands, DJs etc. If So Please Explain: *

How long before closing does food service stop? *

(Enter minutes or hours — ex: 0, 30 min, 1 hour, etc.)

How long before closing does alcohol service stop? *

(Enter minutes or hours — ex: 0, 30 min, 1 hour, etc.)

What hours is the owner at location? *

SAFETY FEATURES:

Types Of Kitchen Appliance (Check All That Apply) *

Any Table Side Cooking? *

Yes
No

What % Of The Entire Restaurant Is Fully Sprinklered? *

Is the ansul system UL300 compliant *

Yes
No

Automatic fire extinguishing system provides surface protection for all cooking surfaces? *

Yes
No

Automatic Extinguishing System Serviced No Less Than Every 6 Months *

Yes
No

What Company Name Services Them? *

Do metal hoods and ducts cover all cooking surfaces? *

Yes
No

What Company Name Services Them (monthly, quartlery or semi-annual)?: *

Hoods equipped with removable filters or grease extractors vented to outside of building? *

Yes
No

All cooking or heating devices installed with minimum 18 inches safe clearance to combustible walls, ceilings, etc? *

Yes
No

Manual pull for extinguisher system readily accessible and clearly identified? *

Yes
No

All gas fired cooking equipment and electric deep fat fryers equipped with automatic fuel shut off? *

Yes
No

All deep fat fryers equipped with thermostat with automatic fuel shutoff if temperature exceeds 475 degrees? *

Yes
No

Is refrigeration/freezing equipment under a maintenance agreement? *

Yes
No

Does refrigeration/freezing equipment have an alarm if not properly working? *

Yes
No

Central Burglar Alarm System? *

Yes
No

Central Fire Alarm System? *

Yes
No

Is there video surveillance inside the restaurant? *

Yes
No

Please Tell Us Anything Specific We May Need To Know: Landlord requirements, Claims history, Important business activity, etc.

Workers Compensation & Paid Family Leave/Disability

List full names of all legal owners *

Please list each job position & total combined annual payroll per that position (EXCLUDE OWNERS) *

(ex: Servers $250,000 combined payroll, bartenders $200,000 combined payroll)

How many Full Time Employees? *

How many Part Time Employees *

How many Male employees? *

How many Female employees? *

Claims History

In the past 5 years, do you have any open or closed claims? If yes, please describe the claim description, claim date, claim amount: *

If accessible, please upload your 5 Year Currently Valued Loss Run Report: