RESTAURANT / BAR / TAVERN APPLICATION
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE”
Name of Applicant:
Mailing Address:
Contact Name:
Contact Phone:
Business Phone:
Business Fax:
E-mail:
Web site Address:
Business Location (if different than the above mailing address):
City:
State:
Zip:
Inspection contact name and telephone number:
Audit contact name and telephone number:
Form of business:
Individual
Partnership
Corporation
PROPOSED EFFECTIVE DATE:
Other:
PROPOSED EXPIRATION DATE:
Business Operations:
1. Total receipts from all operations: $
2. Provide percentage of total receipts for each exposure listed below:
Restaurant ................................................
%
Bowling Alley .....................................................
%
Bar ..........................................................................
%
Strip/Adult Entertainment ..................................
%
Tavern .......................................................
%
Comedy Club ....................................................
%
Nightclub ...................................................
%
Brew Pub...........................................................
%
Biker Bar ...................................................
%
Private/Fraternal Club .......................................
%
Pool Hall ...................................................
%
Other(Explain): .................................................
%
3. Is this a new venture? ..................................................................................................................................
Yes
No
Yes
No
Additional operations on premises:
4. Provide number of apartment units on premises:
5. Is building or premises Lessor’s Risk Only? ................................................................................................
a. If yes, provide: total square feet:
Type of occupancy:
Applicant maintains:
square feet
Name of Lessor Risk Tenant:
b. Does Applicant hold harmless agreement? ..........................................................................................
Yes
No
If yes: Does Applicant hold a Certificate of Insurance? ........................................................................
Yes
No
If yes: Is Applicant named as an additional insured on Lessee’s policy? .............................................
Yes
No
Yes
No
Yes
No
6. Square feet of business office:
7. Square feet of warehouse:
8. Any gift shop receipts? ................................................................................................................................
If yes, provide receipts.
9. Any other operations not identified above? .................................................................................................
WHI APP-146 (07-10)
Pacificcoastes.com
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RESTAURANT / BAR / TAVERN APPLICATION
Explain:
10. PRIOR CARRIER INFORMATION
Year:
Year:
Year:
Year:
Year:
Carrier
Policy Number
Property Coverage
General Liability
Liquor Liability
Crime
Total Premium
11. LOSS HISTORY—THREE YEAR PERIOD
Indicate all claims or losses (regardless of fault and whether or not insured) or occurrences that may give rise to
claims for the prior five years.
Check box if no claims.
Date of
Loss
Type of
Coverage
Description of Loss
Amount Paid
Amount
Reserved
Claim
Status
(Open or
Closed)
12. Is current carrier willing to renew? ...............................................................................................................
Yes
No
13. Has applicant ever been cancelled or non-renewed for any reason other than non-payment, carrier’s
termination of a class, program or state (Not applicable in Missouri)? .......................................................
Yes
No
14. Any assault and battery claims in the past three years? .............................................................................
Yes
No
15. Any mold claims in the past three years? ....................................................................................................
Yes
No
16. Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring? ..................................................................................................................................................
Yes
No
17. Any non-owned or hired auto liability claims in the past three years? ........................................................
Yes
No
18. Any bankruptcies, tax or credit liens against the applicant in the past five years? .....................................
Yes
No
19. During the past ten years, has any applicant been convicted of an arson crime? ......................................
Yes
No
If yes, provide reason or reasons for cancellation or non-renewal:
WHI APP-146 (07-10)
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RESTAURANT / BAR / TAVERN APPLICATION
20. Provide loss details of all losses in excess of $2500:
Property Information
1.
Location (Physical address):
Subject of Insurance
Amount
Co-Insurance
Percent
Building
%
Tenant Improvements
& Betterments
%
Business Personal
Property
%
Valuation
Coverage
Form
Deductible
Business Income:
With Extra Expense
%
Without Extra Expense
%
Coinsurance percentage or Monthly Limitation
Property Enhancement Endorsement (available with Causes Of Loss Special Form only)....................
Yes
No
NOTE: A minimum deductible of $500 applies to this coverage. This endorsement provides additional limits of insurance as follows:
Accounts Receivable—$25,000
Computer Equipment—$25,000
Outside Signs—$10,000
Spoilage—$25,000
Valuable Papers—$25,000
Fine Arts—$15,000
Money & Securities—$25,000
Employee Dishonesty—$10,000
Property of Others—$10,000
Back-up of Sewer & Drains—$15,000
Outdoor Property—$10,000
Property in Transit—$15,000
Construction Type:
2.
Protection Class:
No. of stories:
Provide year of building updates:
Year Built:
Area Occupied by Applicant:
Partial or complete updates:
Electricity
Plumbing
Roofing
HVAC
3. Building entirely sprinklered? .......................................................................................................................
Yes
No
If no, is applicant’s business areas sprinklered? .........................................................................................
Yes
No
4. Are there any lakes, ponds or boat slips? ...................................................................................................
Yes
No
5. Are there smoke detectors? ........................................................................................................................
Yes
No
Yes
No
Yes
No
If yes, hard wired or battery operated?
6. Are there fire alarms? ..................................................................................................................................
If yes, central station, local or pull alarms operated?
7. Are there burglar alarms? ............................................................................................................................
WHI APP-146 (07-10)
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RESTAURANT / BAR / TAVERN APPLICATION
If Yes, central station or local operated?
8. Is there aluminum wiring on premises?
Yes
No
Yes
No
10. Are all fire exits clearly marked? ..................................................................................................................
Yes
No
11. Is there a secondary means of egress on each floor? ................................................................................
Yes
No
12. Emergency lightning in common areas? .....................................................................................................
Yes
No
13. Are fire extinguishers tagged and serviced within past twelve (12) months?..............................................
Yes
No
14. Is there a formal safety program in place? ..................................................................................................
Yes
No
15. Is business operation seasonal? .................................................................................................................
Yes
No
If yes, describe:
9. Is the aluminum wiring repaired? .................................................................................................................
Describe:
If yes, by whom:
If yes, date business closes:
Date business reopens:
16. What percentage of the building is in course of construction or being renovated? .........................................
%
17. What percentage of the building is vacant? ....................................................................................................
%
18. Are pyrotechnic or foam machines used? ...................................................................................................
Yes
No
19. Is sawdust used on the floor for esthetics? .................................................................................................
Yes
No
20. Are circuit breakers used in the building? ...................................................................................................
Yes
No
21. Any knob and tube wiring in building? .........................................................................................................
Yes
No
22. Is roof flat? ...................................................................................................................................................
Yes
No
Yes
No
a. Are hoods and ducts equipped with filters? ..........................................................................................
Yes
No
b. Any sub-contracted cooking facilities? ..................................................................................................
Yes
No
d. Are hoods and ducts equipped with filters? ..........................................................................................
Yes
No
e. Any tableside cooking? .........................................................................................................................
Yes
No
Are UL approved “K” portable fire extinguishers mounted and accessible to cooking areas? .............
Yes
No
27. Is raw seafood served? ...............................................................................................................................
Yes
No
Yes
No
23. Roof construction (shake, shingle or tile)?
24. Plumbing material used (e.g. PVC, copper, iron, lead, etc.)?
25. Is there a current service contract for maintenance of refrigeration equipment? ........................................
If yes, how often is service performed?
26. Restaurant/Cooking Operations: Check the box if no cooking on premises
c.
Type of cooking (check all that apply):
Deep Fat Fryers
Pizza Oven
Griddles
Microwave
BBQ Grill Pit
f.
If yes, describe:
28. Are banquet facilities available? ..................................................................................................................
WHI APP-146 (07-10)
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Santa Rosa
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RESTAURANT / BAR / TAVERN APPLICATION
If yes, square footage:
29. Any off premises catering? ..........................................................................................................................
Yes
No
30. Is there a UL certified automatic suppression system over all cooking surfaces and deep fat fryers? .......
Yes
No
If yes, does system have an automatic shut-off? ........................................................................................
Yes
No
If yes, provide type of system? ...................................................................................................................
Wet
Dry
If yes, does the UL certified automatic suppression system include an automatic gas or electric shut-off
with a manual pull capacity? ........................................................................................................................
Yes
No
Yes
No
Yes
No
Yes
No
31. Any background checks on employees prior to hiring? ...............................................................................
Yes
No
32. Are bank deposits made frequently? ...........................................................................................................
Yes
No
If yes, at irregular times? .............................................................................................................................
Yes
No
33. Is there a drop safe? ....................................................................................................................................
Yes
No
35. Any twenty-four (24) hour operation? ..........................................................................................................
Yes
No
If yes, camera surveillances at door? ..........................................................................................................
Yes
No
If yes, is there a buzzer to allow entry after 1:00 a.m.? ...............................................................................
Yes
No
If no, explain:
a. Is there an independent cleaning contract for hoods and ducts? .........................................................
If yes, how often is system cleaned?
b. Is there an independent cleaning contract for the automatic extinguishing system? ...........................
If yes, how often is system cleaned?
c.
Have there been any Health Department violations? ...........................................................................
If yes, describe:
Crime Information
If yes, how often during the day?
If yes, who has keys?
34. Maximum amount of money at each cash register:
General Liability Information
Coverage
Coverage
Limits of
Liability
Limits of
Liability
Each Occurrence
Medical Expense (any one person)
General Aggregate
Liquor Legal (Each Comm. Cause)
Product/Completed Operations Aggregate
Liquor Legal (Annual Aggregate)
Personal and Advertising Injury
Non-owned and Hired Auto
Fire Damage (any one premise)
Employers Liability
Additional Interests (Additional Insureds, if acceptable, are subject to $100 each, plus any applicable tax):
Name:
Attn.:
Mailing Address:
Indicate type of interest:
WHI APP-146 (07-10)
Pacificcoastes.com
Certificate Holder only
Additional Insured and Certificate Holder
Loss Payee
Page 5 of 11
Santa Rosa
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Seattle
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RESTAURANT / BAR / TAVERN APPLICATION
Contract of Sale
Mortgagee
Describe the insurable interest:
Gross Sales by Category—Projected for Policy Term
Food
Beer/Wine/Liquor—Off Premises
Beer & Wine (On premises consumption)
Off Premises Catering
Other Liquor (On premises)
Other Receipts
Receipts—Current Year
Total Projected Receipts
Total Receipts—Last Year
Source of Other Receipts
Total Receipts—Prior Year
1. How many days per week is this location open?
2. What time does the business open?
3. What is the latest closing time?
4. What is the building’s legal maximum occupancy established by the fire marshal or fire department?
5. Average number of patrons on premises during peak hours:
6. Maximum number of patrons on premises at any one time:
7. Are all exists equipped with panic door hardware? .....................................................................................
Yes
No
8. Are all exists kept unlocked during business hours?...................................................................................
Yes
No
10. Are all means of egress marked with lighted exist signs? ...........................................................................
Yes
No
11. Is there emergency lighting? .......................................................................................................................
Yes
No
Yes
No
Armed? ........................................................................................................................................................
Yes
No
If not armed, are armed guards contracted? ...............................................................................................
Yes
No
16. Are firearms kept or permitted on the premises? ........................................................................................
Yes
No
Yes
No
9. Number of exits:
12. What area of the parking lot is under the control of the applicant?
13. Any valet parking? .......................................................................................................................................
14. Describe surface of parking lot:
Dirt
Gravel
Concrete
Asphalt
No parking lot
Other: Explain
15. Number of employees by category:
Managers:
Bartenders:
Waiter/Waitresses:
Security/Bouncers:
17. Number of times per year police are called to the business location?
If called, provide details:
18. Does applicant sponsor any athletic activities events or teams? ................................................................
WHI APP-146 (07-10)
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Santa Rosa
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F 707-573-9761
Seattle
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RESTAURANT / BAR / TAVERN APPLICATION
19. Is there a children’s designated play area? .................................................................................................
Yes
No
20. Any volleyball courts, basketball courts or batting cages on premises? .....................................................
Yes
No
21. Any guard dogs or any animal on premises during or after business hours? .............................................
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
If yes, explain:
Entertainment Liability Information
Entertainment:
Check box if no entertainment on premises and skip to next section.
22. Is there a dance floor? .................................................................................................................................
If yes, dance floor square footage:
23. Any mechanical devices on premises? .......................................................................................................
If yes, describe:
24. Any gambling devices, slots or tables on premises?...................................................................................
If yes, describe:
25. Any pool or billiard tables on premises? ......................................................................................................
If yes, describe:
26. Any athletic events sponsored on or off premises?.....................................................................................
If yes, describe:
27. Any promotional events, such as Teen Night, Wet T-Shirt or Foam Contest, on or off premises?.............
If yes, describe:
28. Any special activities, such as mud wrestling, bungee jumping, velcro suits or mosh pits on or off
premises? ....................................................................................................................................................
If yes, describe:
29. Other special or promotional activities?.......................................................................................................
If yes, describe:
Live Entertainment Information
30. Live Entertainment:
Check box if no entertainment on premises and skip to next section.
31. Is a DJ provided? .........................................................................................................................................
If yes, describe:
32. Any karaoke type entertainment? ...............................................................................................................
If yes, describe:
33. Any topless or go-go dancing? ....................................................................................................................
If yes, describe:
34. Any comedians or stand-up entertainers provided? ....................................................................................
If yes, describe:
35. Any live performers: . Country?.....................
Yes
No. If yes, number of nights per week
Piano/solo acts? .........
Yes
No. If yes, number of nights per week
WHI APP-146 (07-10)
Pacificcoastes.com
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Santa Rosa
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RESTAURANT / BAR / TAVERN APPLICATION
Rock/disco?................
Yes
No. If yes, number of nights per week
Other? ........................
Yes
No. If yes, number of nights per week and describe:
36. Any national known performers provided? ..................................................................................................
Yes
No
Yes
No
Yes
No
Smoke? .......................................................................................................................
Yes
No
Pyrotechnics? ..............................................................................................................
Yes
No
Other live entertainment? ............................................................................................
Yes
No
39. Is business considered a concert venue? ...................................................................................................
Yes
No
Yes
No
If yes, describe:
37. Any promoters? ...........................................................................................................................................
If yes, describe:
38. Any special effects: Lighting/Sound?
If yes, describe:
If yes, describe:
40. Are the premises sublet or rented out for use by others as a nightclub? ....................................................
If yes, describe:
41. Can tickets for shows/bands be purchased on line or at the door?
Liquor Liability Information
42. Liquor Liability:
Check box if coverage not requested and skip to next section.
43. Liquor Liability Coverage:
Limits of Insurance:
44. Effective date:
$300,000
$500,000
$1,000,000
Other:
Liquor License number:
Type:
Beer & Wine
Full Liquor
45. Any special promotions/drinks, such special consumption promotions such as ladies night, 2 for 1, etc?
Yes
No
46. Are customers allowed to bring their own bottles or liquor set ups? ...........................................................
Yes
No
47. Any flaming drinks served? .........................................................................................................................
Yes
No
If yes, describe:
If yes, describe:
48. Provide customers demographic age by percentage: under 25:
over 54
%.
%
25 -34
%
35-54
%
49. Are patrons under twenty-one (21) allowed on premises? ..........................................................................
Yes
No
51. Any off premises dispensing of alcoholic beverages for off-premises events? ...........................................
Yes
No
52. Has applicant, any owner, partner or officer of licensee ever had a liquor license revoked or
suspended? .................................................................................................................................................
Yes
No
50. Provide drink prices by type: Cocktails: $
Wine: $
to $
to $
Beer: $
to $
If yes, describe:
WHI APP-146 (07-10)
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RESTAURANT / BAR / TAVERN APPLICATION
53. Any liquor violations in past three years? ....................................................................................................
Yes
No
Yes
No
55. Is training or guidance provided for servers in the handling of minors or intoxicated customers?..............
Yes
No
If yes, are there written guidelines for handling minors and intoxicated customers? ..................................
Yes
No
If yes, how many:
54. Have authorities been called to your premises for any reason during the past five years? ........................
If yes, describe:
If yes, what percentage of servers have training? ...........................................................................................
%
56. Are servers trained in tips/tops within sixty (60) days of employment? .......................................................
Yes
No
57. Are customers served without checking age identity? ................................................................................
Yes
No
If no, are there written guidelines? ..............................................................................................................
Yes
No
58. Is a “bouncer” employed? ............................................................................................................................
Yes
No
59. Does applicant currently carry Liquor Liability Insurance? ..........................................................................
Yes
No
Yes
No
Yes
No
63. Does applicant verify each employee driving for business purposes has a valid government issued
driver’s license and carries sufficient personal insurance in accordance with minimum state insurance
requirements? ..............................................................................................................................................
Yes
No
64. Does applicant prohibit business driving rights for any individual with prior incidence of license suspensions, revocations or DUI of alcohol or illegal drugs ? ................................................................................
Yes
No
65. Is off-site catering or delivery service provided? .........................................................................................
Yes
No
66. Any hired and non-owned auto losses in past five years? ..........................................................................
Yes
No
67. Are employees required to use their personal vehicles to conduct applicant’s business? .........................
Yes
No
If yes, is evidence of auto liability insurance such as a Certificate of Insurance obtained and maintained
on file? .........................................................................................................................................................
Yes
No
Yes
No
If yes, provide the following: Name of Carrier:
Policy Type:
Occurrence Form
; Limit of Liability:
Claims Made Form
60. Has applicant had Liquor Liability Insurance coverage denied, canceled or non-renewed during the last
three years (Not applicable in Missouri)? ....................................................................................................
If yes, provide details:
61. Has applicant had any past incident that may give rise to a claim? ............................................................
If yes, provide details, including possible liability amounts payable:
Hired and Non-Owned Auto Information
62. Hired and Non-Owned Auto Coverage:
Check box if coverage not desired and skip to next section.
If yes, how many trips are made per month?
68. How often are MVRs and auto liability insurance reviewed to ensure both are valid and current?
Valet Parking Information
69. Valet Parking:
Check box if coverage not requested and skip Questions 69 through 72.
70. Is valet parking offered? ..............................................................................................................................
WHI APP-146 (07-10)
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RESTAURANT / BAR / TAVERN APPLICATION
If yes, is valet parking performed by the applicant’s employees? ...............................................................
Yes
No
71. Are valet parking attendants driving records checked?...............................................................................
Yes
No
72. Is valet parking performed by a subcontractor? ..........................................................................................
Yes
No
a. Does outside firm have insurance coverage in force to cover liability arising out of valet parking including physical damage to customer’s autos? ....................................................................................
Yes
No
b. Is applicant included as an insured under the outside firm’s garage and garagekeepers insurance? .
Yes
No
73. Is the business operation in compliance with ADA requirements? .............................................................
Yes
No
If yes, the following questions must be answered:
THE APPLICANT REPRESENTS THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT TO THE BEST OF
HIS OR HER KNOWLEDGE, AND THAT NO MATERIAL OR RELEVANT FACTS HAVE BEEN SUPPRESSED OR
MISSTATED AND AGREE THAT THE POLICY, IF ISSUED, WILL BE ISSUED ON THE RELIANCE OF SUCH
REPRESENTATIONS.
Applicant acknowledges a continuing obligation to report to us or your agent as soon as practicable any material changes
in the facts or statements above, and in each supplementary application, which applicant becomes aware after signing the
application.
Completion of application or tendering of premium does not bind coverage. Application is subject to the company’s guidelines. Applicant’s acceptance of company’s quotation is required prior to binding coverage and policy issuance. It is
agreed that this application shall be the basis of the contract of insurance should a policy be issued and it will be attached
to the policy.
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the information contained herein shall be the basis of the contract should a policy be issued.
FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and
subjects such person to criminal and civil penalties. Not applicable in Nebraska, Oregon and Vermont.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may
include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance
company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for
the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: It is a crime to provide false or misleading information to
an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In
addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony in the third degree.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
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NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of
insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is
guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE TO OHIO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and
subjects such person to criminal and civil penalties.
NOTICE TO OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
FRAUD WARNING (Applicable in Tennessee, Virginia and Washington): It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTICE TO NEW YORK APPLICANTS (Other than automobile): Any person who knowingly and with intent to defraud
any insurance company or other person files an application for insurance or statement of claim containing any materially
false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a
fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars
and the stated value of the claim for each such violation.
I/We hereby declare that the above statements and particulars are true and I/We agree that this application shall be the
basis of the contract with the insurance company. Any missing or erroneous information in this Application may jeopardize
coverage in the event of a claim under any policy issued by us.
APPLICANT’S NAME:
APPLICANT’S SIGNATURE:
DATE:
(Must be signed by an authorized owner, partner or executive officer)
AGENT NAME:
AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional
information as to the nature and scope of the report, if one is made, will be provided.
Please send completed application to WAAPP@pacificcoastes.com, and / or CAAPP@pacificcoastes.com
WHI APP-146 (07-10)
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