New Customer Application

Business Name*

Owner's Name*

Contact Name*

Contact Cell Phone*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Proposed Effective Date*

Years in Business*

Years restaurant management experience of owner/manager*

FEIN #*

Entity Type*

Type of Restaurant*

Please check all that apply

Quick Service (no table service)
Casual Dining (table service)
Upscale
Cafeteria/Buffet
Ice Cream/Beverage Shop
Other

If Other, Please Describe*

Do you own any other business operations/entities under the Name listed above?*

If Yes, Please Describe*

Please List Location Address(es)*

Please use the "+" and "-" buttons to add and remove locations to this list.

Location Name	Street 1	Street 2	City	State	Zipcode

Location Information*

Please use the "+" and "-" buttons to add and remove locations to this list.

Location Name	Eat In Sales	Carry Out Sales	Delivery Sales	Alcohol Sales	Restaurant Hours	# of Employees	Seating Capacity	# of Servcers

Location Property Information

Please use the "+" and "-" buttons to add and remove locations to this list.

Location Name	Owner or Tenant	Building Value (if Owned)	Business Personal Property Limit	Tenant Betterments & Improvements	Standalone or Strip Mall	Sq Ft of Building	Sq Ft of Restaurant

Location Property Information - Continued*

Building Type = Examples are Frame, Steel, Concrete, Brick, etc. **= If Year Built is Older than 1985, when was the last time a certified technician worked on or verified the working order / condition of the following... Also, Please use the "+" and "-" buttons to add and remove locations to this list.

Location Name	Roof Type	Year Built	Construction Type	Roof **	Plumbing **	Heating **	Electrical **

Do any of the locations have the following:

Overhead Sprinklers
Central Burglar Alarm
Central Fire Alarm
Security Cameras
Habitational Exposure (Ex: Apartments in the Building)
Children's Play Area (Ex: Bounce House, Arcade Room, etc)

Please check all that apply.

For Overhead Sprinklers, please list each location that has them

For Central Burglar Alarm, please list each location that has them

For Central Fire Alarm, please list each location that has them

For Security Cameras, please list each location that has them

For Habitational Exposure, please list each location that has them

For Children's Play Area, please list each location that has them

Please also describe the type of play area for each location.

Contents

1 General Operations
2 Additional Coverages
3 Money and Securities
4 Liquor Liability
5 Workers Compensation
6 Kitchen Facilities
7 Expiring Coverage Information
8 Signature

General Operations

Are deliveries made?*

Yes
No

If Yes, Delivery Types*

Residential
Business to Business

Delivery associated with catering operations only*

Yes
No

Delivery by employees?*

Yes
No

Delivery by Employee-owned autos?*

Yes
No

Delivery By Company-Owned Autos?*

Yes
No

If Company-owned, is the title of the vehicle in the business’ name?*

Yes
No

If Company-owned, Company-owned autos used for delivery?*

Yes
No

If no, what is primary use of company owned autos?*

Delivery by Scooter/Moped/Bicycle?*

Yes
No

Do you currently have a driver training course in place?*

Yes
No

Do you guarantee delivery time?*

Yes
No

What is the minimum driver age?*

Is valet parking service provided?*

Yes
No

If Yes, by whom?*

Applicant
Third Party

Delivery by third party vendor(s)?*

Yes
No

If employees use their own vehicles on company business, does the Insured monitor evidence of personal auto insurance?*

Yes
No

Are hold harmless agreements in applicant’s favor and Certificate of Insurance naming applicant as additional insured obtained for all independent contractors or vendors?*

Yes
No

If no, please explain*

Do you provide off-site catering?*

Yes
No

If yes, total receipts from catering*

Catering Services include:*

Deliver only?
Deliver, set-up and serve?
Deliver and set up?
Serve alcohol?

Are the applicant and all employees bonded for theft?*

Yes
No

Are you interested in Employment Practices Liability?*

Yes
No

If Interested in Employment Practices Liability*

$100,000 Limit
$1,000,000 Limit

Retroactive Date*

Additional Coverages

Are you interested in Money and Securities Coverage?*

Yes
No

Are you interested in Liquor Liability Coverage?*

Yes
No

Are you interested in Workers Compensation Coverage?*

Yes
No

Money and Securities

Does the insured maintain a cash register and records of daily receipts?*

Yes
No

Are deposit records kept on premises?*

Yes
No

Are daily bank deposits made?*

Yes
No

If no, how often are bank deposits made?*

Is money stored in a class B safe or better while on premises?*

Yes
No

Liquor Liability

Is the Insured serving hard liquor?*

Yes
No

Does the insured deliver alcohol?*

Yes
No

Is there a stand-alone bar/cocktail lounge?*

Yes
No

Is a food menu available during all hours of liquor service?*

Yes
No

Has applicant had any reported liquor liability claims or notification of potential liquor liability claims in the last five years?*

Yes
No

If Yes, Please Expain*

Has applicant’s liquor liability coverage ever been cancelled or non-renewed?*

Yes
No

If Yes, Please Expain*

Has the applicant had any fines, citations, or license suspensions or revocations for violations of liquor sales laws or ordinances?*

Yes
No

If Yes, Please Expain*

Are all servers certified in a formal alcohol training course (e.g., TIPS, TAM, RAMP, ServSafe, etc.)?*

Yes
No

In addition to use of a certified alcohol training course, does applicant have a written policy for serving alcohol?*

Yes
No

Does management review this written policy with servers on a regular basis?*

Yes
No

Does applicant have any alcohol consumption promotions/happy hours?*

Yes
No

If yes, describe the promotions and how consumption quantities are controlled*

Does applicant provide entertainment, dancing, live bands, a DJ, or amusement devices?*

Yes
No

If yes, describe*

Does applicant use any on-site security or bouncers?*

Yes
No

Workers Compensation

# FT EEs # PT EEs FEIN (federal employment identification number) Estimated Annual Restaurant Payroll Estimated Annual Delivery Payroll

# of Full Time Employees*

# of Part Time Employees*

Estimated Annual Restaurant Payroll*

Estimated Annual Delivery Payroll*

Kitchen Facilities

Percentage of food receipts from grease laden cooking (deep fat frying/grilling)*

Does an outside firm clean hoods and ducts?*

Yes
No

If yes, frequency of service*

Quarterly
Semi-Annually
Annually

Does a UL300 approved automatic extinguishing system cover all cooking surfaces*

Yes
No

If no, explain exceptions:*

Is there an automatic extinguishing system?*

Yes
No

Is the system under a service maintenance contract by an outside firm?*

Yes
No

If yes, frequency of service*

Quarterly
Semi-Annually
Annually

How often are hood filters cleaned?*

Daily
Weekly
As needed, more frequently than weekly
Less frequently than weekly

Does prospect have current coverage?*

Yes
No

Expiring Coverage Information

BOP - Business Owners Package*

Carrier	Policy #	Exp. Date	Premium

Auto*

Carrier	Policy #	Exp. Date	Premium

Expiring Sales Information*

Expiring Total Sales	Expiring Eat-In Sales	Expiring Alcohol Sales	Expiring Delivery Sales	Expiring Carry Out Sales

Signature

Signature*

Untitled

New Customer Application

General Operations

Additional Coverages

Money and Securities

Liquor Liability

Workers Compensation

Kitchen Facilities

Expiring Coverage Information

Signature

Request a Quote

Contact

Most Popular

Legal