Restaurant Liability
Commercial Property Commercial General Liability Liquor Liability
Are you filling this out on behalf your client?
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Yes
No
I am a(n)
Insurance Broker
Real Estate Agent
Lender / Mortgage Broker
Other
Name
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First Name
Last Name
Name of Restaurant?
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Email
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example@example.com
Phone Number
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-
Area Code
Phone Number
State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Select the Lines of Business to Quote
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Commercial Property
Commercial General Liability
Liquor Liability
Have there been any losses/claims, Liquor citations, violations, charges or enforcement actions at this location in the past five years?
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Yes
No
Unknown
Year Established
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What are the annual sales generated by food?
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What are the annual sales generated by liquor?
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"Other" annual receipts? i.e. cover charge, vending, t-shirt sales, etc.
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Total Sales
How many nights of major entertainment per week? (Major Entertainment - Bands with 3 or more members, excluding Jazz Bands; DJ with dancing, Dance Clubs, Dance Halls or Adult or Exotic Dancing and not including banquet entertainment.)
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Does the establishment feature adult/exotic dancing?
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Yes
No
Is dancing permitted?
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Yes
No
Are there tables?
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Yes
No
Is there table service?
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Yes
No
Is the establishment located within a food court with no responsibility for the seating area?
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Yes
No
Is the establishment open 24 hours?
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Yes
No
What time does the establishment close? (ex. 8:00 PM)
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Is the establishment primarily open for banquets, receptions, or private affairs?
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Yes
No
Is the average entrèe price* greater than $20 (*Including the price of one side dish if side dishes are charged separately); and is the average wine price greater than $30 per bottle; and does the number of bottles on the wine list exceed 10; and is the last dinner seating is 10:00PM or earlier?
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Yes
No
Is the establishment primarily a non-profit Private, Fraternal, or Social Club?
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Yes
No
Are same-day memberships available; or are members permitted to bring more than 3 guests per day (excluding banquet activities and immediate family members)?
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Yes
No
Describe the establishment
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Billiard or Pool Hall
Bowling Alley
Country Club
Restaurant / Bar
Are bouncers, security or doorpersons ever employed?
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Yes
No
Unknown
Applicant Name
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Select the Quote Term
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Annual
3 month
6 month
9 month
How many years has the applicant been at the current location?
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Is a United States Liability Insurance Group company the expiring carrier? (United States Liability Insurance Co., Mt. Vernon Fire Insurance Co., U.S. Underwriters Co. or Mt. Vernon Specialty Insurance Co.)
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Yes
No
Description of Operations
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Location Address
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Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Mailing same
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Yes
No
Mailing Address
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Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Property
Building Construction
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Frame
Joisted Masonry
Non Combustible
Masonry Non Combustible
Modded Fire Resistive
Fire Resistive
Protection Class
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1
2
3
4
5
6
7
8
9
10
Requested Cause of Loss
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Basic
Special
Requested Valuation
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Replacement Cost
Actual Cash Value
What year was the building constructed?
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What type of plumbing is in the building?
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Unknown
PVC
Copper
Lead
Galvanized
Other
What type of roof is on the building?
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Unknown
Flat - Tar/Gravel
Flat - Concrete
Shingle
Wood Shake/Wood Shingle
Metal
Tile
Slate
Other
Roof Age
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Is the building protected by an operational sprinkler system covering 100 percent of the premises?
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Yes
No
Unknown
Is the establishment the sole occupant of the building?
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Yes
No
Unknown
Are there grills, deep fat frying equipment or woks on the premises?
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Yes
No
What type of extinguishing system is functioning and operational?
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None
Wet
Dry
Unknown
Number of Months per year the business is in operation
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Building Limit
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Business Personal Property
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Commercial General Liability
Select the Per Occurrence Limit
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$1,000,000
$500,000
$300,000
$100,000
Select the General Aggregate Limit
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$2,000,000
$1,000,000
Select the Products/Completed Operations Aggregate Limit
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$2,000,000
$1,000,000
Personal & Advertising Injury Limit
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$1,000,000
Excluded
Select Limit for Damage to Premises Rented to You
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$50,000
$100,000
$250,000
$300,000
$500,000
$1,000,000
Excluded
Select the Medical Expenses (Any one person) Limit
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$1,000
$5,000
$10,000
Excluded
Are there any mechanical riding devices on premises?
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Yes
No
Are bouncers, security or doorpersons ever employed?
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Yes
No
Unknown
What is the latest time the establishment will close? (enter format hh:mm PM or hh:mm AM)?
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Liquor Coverages
Liquor Liability Limits - Per Occurrence Limit
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$1,000,000
$500,000
$300,000
$100,000
Liquor Liability Limits - Per Aggregate Limit
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$2,000,000
$1,000,000
Are facilities available for banquets, receptions or private affairs?
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Yes
No
Unknown
Does the establishment cease the sale of alcohol daily?
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Yes
No
Unknown
What is the latest time the establishment will cease the sale of alcohol? (enter format hh:mm PM or hh:mm AM)
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Are all alcohol-serving employees certified in a formal alcohol training course not mandated by the state?
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Yes
No
Unknown
Does the establishment utilize an identification scanner on all patrons, regardless of age?
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Yes
No
Unknown
Does the establishment permit "BYOB" (bring your own bottle)?
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Yes
No
Unknown
Does the establishment: have a wait staff that actively monitors all alcohol consumption; limit the type of alcohol brought on premises to beer and wine; request a valid ID from all patrons; and have a maximum occupancy of less than 250?
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Yes
No
Unknown
How often does entertainment for banquets or receptions occur at this location annually?
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Is alcohol ever sold or served away from the premises?
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Yes
No
Unknown
Potential Exposures
Add Lessor of Leased Equipment as an Additional Insured?
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Yes
No
Add Manager or Lessor of the Premises as an Additional Insured?
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Yes
No
How many additional insureds of this type?
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What is the name of the Additional Insured?
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What is the full mailing address of the Additional Insured?
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does the establishment, as the building owner, lease any apartments on the premises?
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Yes
No
How many units are there?
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What is the total square footage for all units?
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What is the square footage of the entire building?
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What percentage of the units are occupied by student tenants? (not applicable in DC)
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Is liquor or wine sold for off-premises consumption?
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Yes
No
What is the annual gross sales?
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Is beer sold for off-premises consumption?
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Yes
No
What is the annual gross sales?
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Does the establishment, as the building owner, lease any portion of the building to commercial tenants?
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Yes
No
What is the total area?
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Does the establishment provide any off-premises catering?
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Yes
No
What is the annual gross sales?
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Are there any gaming machines on the premises?
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Yes
No
Number of gaming machines
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Add "Waiver of Transfer of Rights of Recovery Against Others to Us"?
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Yes
No
How many people or organizations need endorsement CG 2404?
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Liquor Coverages
Add Additional Insured - Designated Person?
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Yes
No
Exposure Basis
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Add Additional Insured - Grantor of Franchise?
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Yes
No
Exposure Basis
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Add Additional Insured - Liquor License Holder? (Not automatically included on a Basic Coverage option)
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Yes
No
Exposure Basis
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Add Additional Insured - Manager or Lessor of Premises?
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Yes
No
Other
Exposure Basis
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Is there a retail/takeout sales exposure to alcohol that is consumed off premises?
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Yes
No
Exposure Basis
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Does the establishment cease the sale of alcohol daily?
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Yes
No
What is the latest time the establishment will cease the sale of alcohol? (enter format hh:mm PM or hh:mm AM)
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Are all alcohol-serving employees certified in a formal alcohol training course not mandated by the state?
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Yes
No
Does the establishment utilize an identification scanner on all patrons, regardless of age?
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Yes
No
Does the establishment attract a predominantly youthful clientele ranging from 18 to 25 years of age (local provincial minimum drinking age applies)?
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Yes
No
Does the establishment attract a predominantly youthful clientele ranging from 21-25 years of age?
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Yes
No
Is alcohol ever sold or served away from the premises?
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Yes
No
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