Restaurant Program - Supplemental Application
Date: 
1.  DBA:
2.  Risk Location:
3.  Owner's Restaurant Experience: Years (total)     Years (this location)
4.  The Owner is: Manager Cook Investor Other:
5.  Did any prior carrier: Cancel Non-Renew? If so, explain:
6.  Restaurant is: Fast Food Table Service Other:
7.  Hours Open: to
8. 

Building Construction is: Frame/Stucco Masonry Other:

9.  Roof Construction is: Tile/Composition Wood/Shake Other:
10.  Building Age: years.
  If older than 25 years, when was plumbing and wiring brought up to code?
11.  Building Sprinklered? No Fully Partially (explain):
12.  Burglar Alarm? No Yes Local Central
13.  Parking Lot: Owned/Occupied by Insured Shared with Shopping Center Valet Parking
  Other:
14.  Immediate Neighbors
  Left:       Dist. Apart:
  Right:       Dist. Apart:
  Rear:       Dist. Apart:
15.  Are there any residentials (e.g. apartments) in this building? Yes    No.
  If "yes," please explain:
16.  Total restaurant area:     Customer area:
17.  Restaurant has: Full Bar    Beer/Wine    None
18.  Delivery: Yes    No
19.  Entertainment: None    Yes, Describe:
20.  Any Dancing? No    Yes, Describe:
21.  Annual Gross Receipts: Food     Liquor
22.  Will restaurant be closed for remodeling/building construction work during the policy period?
No    Yes, explain:
23.  Any Cooking at tables? No    Yes, explain:
24.  Any Outside Catering? No    Yes
25.  Are customers allowed access to kitchen facilities?
No    Yes, explain:
26.  a)  Is there an automatic suppression system (such as Ansul, Kidde, or other) with an automatic fuel cut-off protecting all cooking areas? No    Yes
  b)  Name of installing/Servicing Company:
  c)  Does the insured maintain a contract with a professional flue cleaning service?
No    Yes   Name of Service:
  d)  Are hoods and ducts cleaned at least once every three (3) months?
No    Yes   Name of Service:
  e)  How often are filters cleaned?
27.  Fire Extinguishers
  a)  Are the fire extinguishers serviced and recharged every 12 months?
No    Yes   Name of Service:
  b)  Date last serviced and recharged:
  c)  Number of extinguishers:
In cooking area    BC Type       In customer area    BC Type
 
Answers to questions 26 and 27 will become a part of the policy and will serve as warranty to the policy as described below:
 
In consideration of the premium at which this policy is written based upon the protection of the premises by protective safeguard systems and services described under 26 and 27 above, it is warranted that answers to questions 26 and 27 are accurate to the Insured's best knowledge and that the Insured shall exercise due diligence in maintaining all equipment in complete working order and service contracts uninterrupted. The Insured will give immediate notice of any impairment or suspension of such equipment or services, to this company.
 
 
Applicant's Signature: ___________________________________________________   Date: _____________

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