| Restaurant Insurance Questionnaire |
| 1. Date:
Expiration date:
Need By (Date):
Need original for closing?
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| 2. For inspection: Mobile #:
Work #:
Home #:
Fax #:
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| 3. Contact Name:
Email:
Name of Bus.
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| 4. Business Owner's Name and Title
Owner is an / a:
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5. Business Address:
City:
County:
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| 6. How many years in Business
Working on your own:
Working for others:
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| 7. Type of Business:
Retail:
Wholesale:
Both:
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| 8. Construction:
Condition:
Year Built:
Year Gutted:
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| 9. What type of product's do you sell?
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| 10. What are your store hours?
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| 11. What type of Cooking Equipment do you have? Deep Fat Fryer(s):
Stove(s):
Grill(s):
Pizza Oven(s):
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| 12. Annual Food Reciepts $
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| 13. Annual Liquor Reciepts $
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| 14. Is it Bar service only? Yes
No
If yes, Number of Stools:
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| 15. Seating Capacity :
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| 16. Is there Entertainment? Yes
No
If yes, Type:
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| 17. General condition of business?
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| 18. Exposure left:
Ft. Exposure right:
Ft. |
| 19. Exposures in building:
any apartments in building? Yes
No
If yes, how many?
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| 20. Do you live in the Building?:
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| 21. Fire insurance needed on contents?: $
on Building?: $
Deductible: $
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| 22. What is your total annual gross receipts?
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| 23. Number of employees:
Full time:
Part time:
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| 24. Do you need worker's comp? Yes
No
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| 25. What is your total annual payroll for employees?
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| 26. What is your total annual payroll for officers (if corporation)?
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| 27. What floor is the business located on? Basement
First
Second
Other
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| 28. Do you have in your possession property of others? Yes
No
If so, how much?
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| 29.Any loss payees or additional insured's?
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| 30. Do you want Robbery and Burglary Insurance? Yes
No
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| 31. Money and Securities?
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32. Does Building have any alarms? Smoke:
Central Burglary:
Central Fire:
Local Gong:
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| 33. Any losses in the past 3 years?
Type of Loss:
Date:
Amount of Loss: $
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| 34. Does Building have a Sprinkler system? Yes
No
Totally sprinklered? Yes
No
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| 35. Do you need Glass Insurance? Yes
No
If Yes...What are the measurements
(Linear Feet):
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| 36. How much liability needed: $
Umbrella amout in Millions: $
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| 37. Do you need any Stock Spoilage Insurance? Yes
No
if yes, How Much?
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| 38. Any additional insured's? Yes
No
If yes, names?
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| 39. Do you need Flood insurance?: Yes.
Distance to water:
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| 40. Account Receivable or Valuable Paper coverage? Yes
No
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| 41. Do you need Employee Dishonesty coverage? Yes
No
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| 42. Do you need Boiler&Machinery Insurance? Yes
No
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| 43. Do you need Computer coverage? Yes
No
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| 44. Value of Computer: Hardware:
Software:
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| 45. Measurements of the building?
x
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| 46. How many floors?
x |
| 47. Updates? When (date): Roof :
Electric:
Plumbing:
Heating:
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| 48. Any Vacancies in the building?:
Any Graffiti on the building?:
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| 49. Any Vacant buildings on block?:
If yes where?
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50. Heating System:
If Oil?
EPA Certified Tank?
Condition:
Oil Tank Above Ground on:
Oil Tank age (If in ground)
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| 51. Do you own any other property or businesses? Yes
No
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| 52. Do you need them quoted? Yes
No
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| 53. What company insures you now:
Current premium: $
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| 54. Why do you want to switch: Pricing:
Switch Agent:
Being Cancelled:
Cancelled:
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| 55. Have you ever been cancelled in the last 3 years?
Why?:
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| 56. Do you make deliveries?
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57. Do you need commercial auto coverage? Yes
No
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| Finish |
| 58. Referred by:
Other:
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| Notes:
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Reproduction of this Questionnaire is restricted unless permission is given.
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