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Restaurant Supp

Restaurant/Bar/Tavern/Nightclub Supplmental Questionnaire

Complete this form in addition to the Acord Application

Restaurant/Bar/Tavern/Nightclub Supplmental Questionnaire

1. INSURED
2. GENERAL INFORMATION:
Number of years in this type of business:
Number of years this business has been in operation:
Business Hours:
Number of days business is open per week:
a. Bouncers? Yes No
If yes, days per week needed:
If yes are they armed? Yes No
If yes, are they ever off duty police officers? Yes No
b. Pool Tables? Yes No
If yes, days per week:
c. Mechanized Device? (i.e. Riding Bull, etc.) Yes No
If yes:
d. Clientele Age: 18 - 25 25 - 35 Over 35 Over 50
e. Live Bands? Yes No
If yes, days per week:
Dance Floor? Yes No
If yes, days per week:
Dancers? Yes No
If yes, days per week:
Female Reviews? Yes No
If yes, days per week:
Male Reviews? Yes No
If yes, days per week:
Disk Jockey? Yes No
If yes, days per week:
Does management ever allow the use of pyrotechnics? Yes No
f. Other Types of Entertainment? Yes No
If yes:
g. Are there any boat docks, slips or ramps associated with the property? Yes No
If yes, provide the number of slips, docking space, or number of boats that can be accomodated:
3. FILL IN FINANCIAL INFORMATION FOR THE PAST THREE YEARS AS REQUESTED BELOW:
a. Fiscal Dates (month & year)
b. Beer, Wine & Liquor Sales
c. Food Sales
d. Total
e. Cover Charge
Name of Person to Contact for Financial Records:
Phone No.:
4. PROPERTY COVERAGE INFORMATION
a. Distance from nearest:
Responding Fire Station (miles):
Fire Hydrant (ft):
b. Year Built:
Number of Stories:
Construction: Frame Other
If other:
c. Total square footage of building:
d. Fire Extinguishers Yes No
If yes, how many?
If yes, serviced & tagged within the past year? Yes No
e. Last date for update of following (show NA if not updated):
Roof:
Plumbing:
Electrical System:
HVAC:
Central station fire or burglary alarm:
Central station fire:
f. Sprinkler system Yes No
If yes, % of square footage covered by sprinkler:
g. Type of wiring Copper Aluminum
Type of roof:
5. COOKING HAZARD QUESTIONNAIRE
a. Is any type of cooking done on premises (please circle if microwave cooking ONLY)? Yes No
b. UL approved auto extinguishing system over ALL cooking surfaces and deep fryers? Yes No
Type of system: Wet Chemical (UL 300 Approved) Dry Chemical
c. Semi-annual service contract for auto extinguishing system? Yes No
d. Automatic gas or electric shutoff for cooking with manual pull? Yes No
e. Are hoods and ducts equipped with filters? Yes No
f. Are filters cleaned at a MINIMUM of every six months? Yes No
g. Are hoods and ducts cleaned at a MINIMUM of every six months? Yes No
h. Are portable fire extinguishers mounted and accessible to cooking areas? Yes No
6. GENERAL LIABILITY INFORMATION
a. Number of Employees:
Managers:
Bartenders:
Waiter/Waitresses:
Security/Bouncers:
b. Area of:
Parking Lot (in square feet):
Is applicant responsible for care/maintenance of lot? Yes No
c. Surface of parking lot Gravel Concrete Asphalt No Parking Other
If other:
d. Number of Exits:
Are all exits marked with exit signs? Yes No
e. Are all exits equipped with panic door hardware? Yes No
If no, are all exits kept unlocked during business hours? Yes No
f. What is the building's legal capacity as established by fire marshal or fire department?
If coverage is provided, it will contain special exclusion (above and beyond normal policy exclusions) including, but not necessarily limited to, the following:
a. Assault and Battery b. Liquor Liability
The Applicant, Agent or Broker represents that the above statements and facts are true and that no mateiral facts have been suppressed or misstated.
Completion of this form does not bind coverage or commit the company to policy issuance.
ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.
Applicant:
Signature:
Date:
Producer:
Producer's Signature:
email

CSL 7003 (09/04)