Contact Information
What is your first name? *
What is your last name? *
What is your email address? *
What is your phone number? *
What is your role at the restaurant?
Please describe your role at the restaurant/bar.
Are you the person to contact to schedule and conduct an inspection of the premises?
What is the full name of the inspection contact?
What is the phone number for the inspection contact?
What is the email address for the inspection contact?
Are you the person to contact to conduct a policy audit at renewal?
What is the full name of the audit contact?
What is the phone number for the audit contact?
What is the email address for the audit contact?
Restaurant / Bar Overview
What is the full legal name of the restaurant? *
Does the restaurant have another name? (ie. DBA)
What other name does the restaurant operate under?
What is the mailing address for the restaurant? *
Is the physical location address the same as the mailing address? *
What is the main physical location address for the restaurant? *
What is the restaurant's website address? (Must begin with http://)
Which legal entity type was the restaurant formed under? *
Please enter the restaurant's legal entity type. *
Please select the classification that fits this restaurant. *
What is the business's Federal Employer Identification Number (FEIN)? *
What year did the restaurant start at this location under the current ownership and management?
How many years experience does the current ownership have in owning or managing this type of operation? *
Please enter a description of the restaurant's operations. *
Please provide the restaurant's hours of operation.
Is this restaurant seasonal? *
Is this location locked and secured during the closed season?
How many months of the year is the business closed?
Does the restaurant engage in rental of the location (or any part of it) for special functions (e.g. weddings, etc.)?
Please provide a description of event types and frequency per year for which the restaurant (or part of it) is rented.
How many locations does the restaurant have?
Does the restaurant currently have insurance in place?
Please provide the following information about your current insurance policies.
Is the current carrier offering to renew the policy? *
What is the reason the current carrier is not offering to renew?
What date would you like this coverage to commence? *
MM slash DD slash YYYY
Claims/Loss/Violation Information
Have there been any losses/claims at any location in the past five years?
Please provide the following information about prior claims/losses. (Click the circle to the right of the table to add losses.)
Have there been any liquor citations, violations, charges or enforcement actions at any location in the past five years?
Please provide the following information about prior citations, violations, or enforcement actions in the past five years. (Click the circle to the right of the table to add incidents.)
Coverage Selection
Please select the coverages desired for this proposal. *
Building/Property Information
Is the restaurant the owner or a tenant of the building? *
What year was the building constructed? *
Please select the building's construction type.
Please select the building's roof type.
What is the age of the roof in years?
What type of construction was used for the walls of the building?
What type of construction was used for the floors in the building?
What type of plumbing is installed in the building?
What is the square footage of the entire structure?
Does the building have other occupants?
Please list the business type for each of the other building occupants. (Use the "+" button to add occupants.)
What is the total square footage occupied by the restaurant?
How many stories does the building have?
Please select the building's heating type.
Please describe the oil tank's location.
What is the age of the oil tank?
Please select the type of electric heat in the building.
Please select the construction elements of the building that have been updated.
What year was the electrical updated?
What year was the plumbing updated?
What year was the heating system updated?
What percentage of the building is sprinklered?
Please select the sprinkler system type.
Are there smoke detectors installed?
Please select the type of smoke detectors that are installed.
Is there a fire alarm installed?
Please select the type of fire alarm installed.
What is the approximate value of the property and equipment owned by the restaurant?
Kitchen Information
Please select the equipment installed in the kitchen.
Are there automatic high temperature shut offs on all deep fat fryers?
Does the restaurant have an automatic extinguishing system?
What type of automatic extinguishing system is it?
Does the automatic fire extinguishing system have a six month maintenance contract in effect?
Is there a maintenance contract for the hood and ducts?
What is the number of maintenance checks scheduled per month?
Are there functioning and operational fire extinguishers according to code?
General Liability
Please enter the restaurant's total annual revenues.
Please enter the annual revenues from food sales for the restaurant. *
Does the restaurant do any catering?
Please enter the annual revenues from catering for the restaurant. *
Does the restaurant offer banquet/reception services?
Please enter the annual revenues from banquet/reception services for the restaurant. *
Does the restaurant offer entertainment?
Please select the type(s) of entertainment offered. (Check all that apply)
Please provide details on the type of playground equipment installed. (e.g. Slides)
Please provide details on the entertainment offered.
Please enter the annual revenues from entertainment sources. *
Please enter the annual revenues from alcoholic beverage sales for the restaurant. *
Does the restaurant provide food delivery?
What is the distance food will be delivered?
Are employee's vehicles used for food delivery?
Is there a commercial automobile policy in force?
Please upload a copy of the commercial automobile policy, if available.
Are the vehicles owned by the restaurant?
Is food delivery sub-contracted out?
Please provide a description of the food delivery services provided.
Workers' Compensation
Please complete the table below with information about your employees. (Click the "+" to the right of the table to add employee types.)
How many seasonal employees are there?
How many previous years of payroll information do you have?
What is the total projected payroll for the current fiscal year?
What was the total annual payroll for the prior fiscal year?
What was the total annual payroll for the next prior fiscal year?
What was the total annual payroll for the third prior fiscal year?
How many shifts does the restaurant have?
How are the employees paid?
Please explain the "other" way the employees are paid.
What is the average hourly wage?
Do you offer paid sick time?
Do you offer paid vacation?
Do you offer a retirement/401k plan?
Do you offer group health coverage?
What percentage is paid by the employer?
Hiring Practices
Do you use a written application in the hiring process?
Do you check references for new employees?
Do you require recent physicals for new hires?
Do you conduct pre-hiring drug testing?
Do you conduct post-accident drug testing?
Do you do motor vehicle report (MVR) checks for new hires?
Do you do criminal background checks for new hires?
Do you document new hire pre-existing injuries?
Are subcontractors used?
What percent of payroll is assigned to subcontractors?
Are certificates of insurance obtained for subcontractors?
Are independent contractors used?
Liquor Liability
Is liquor served on premises?
Provide details below.
Is staff required to take the Smart Serve or similar course to serve alcohol?
Provide details below.
Is I.D. requested from younger patrons prior to serving them alcohol?
Provide details below.
Do you provide taxi service/transportation for intoxicated patrons?
Provide details below.
Is there a Happy Hour?
Provide details below.
Does the restaurant have a bouncer on payroll or a security guard contract in place?
Provide details below.
Has the restaurant's liquor license ever been canceled or suspended?
Provide details below.
Has the restaurant/insured incurred any liquor violations?
Provide details below.
Is there a liquor inventory system?
Please select the inventory system type.
Is there a back up copy of the inventory?
How often is the liquor inventory checked?
Is there any temperature control equipment/rooms for storage of food and wine?
Are the temperature control equipment/rooms alarmed?
Please provide details of the alarms.
Is there a back up generator?
Please upload a copy of the restaurant's liquor license.
Property Maintenance
Who is responsible for the maintenance of the premises including snow removal of walkways and parking lots?
Does the restaurant/insured sub-contract maintenance or snow removal to others?
Please provide details.
Are certificates of insurance obtained from sub-contractor(s)?
Are the CGL limits carried by the sub-contractor(s) at least equivalent to the restaurant's/insured's current policy limits?
Is the restaurant/insured added to the sub-contractor's CGL policy as an additional insured?
Does the restaurant/insured keep sweep and floor maintenance logs for high traffic public areas and areas prone to wetness including restrooms, entrances, and exits?
Does the restaurant/insured keep records of the maintenance schedules?
Does the restaurant/insured keep records of incidents? (e.g. incident log)
Documents and Comments
Please use this field to upload any relevant insurance documents.
Please enter any additional remarks in the space below.
How did you hear about us?
Please share who referred you to us.
Please share what you typed into Google.
Please share how you heard about us.
Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.
