Restaurant Bar Quote Form

INSTANTLY REQUEST A QUOTE

THIS FORM WILL ON AVERAGE TAKE 12 MINUTES TO COMPLETE
Business Name*
DBA*
Phone*
Format: (000) 000-0000.
Email*
example@example.com
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Individual Sole Proprietor (No Incorporation)LLCCorporationOther
Contact Phone Number*
Format: (000) 000-0000.
Contact Name*
Email Address*
example@example.com
Website Address*
When Would You Like Coverage to Start if You Chose Us to Serve You?*
Date Business Started*

MonthDayYear
Date
Provide # years of experience in this trade/business*
YesNo
YesNo
Description of Operations*
YesNo
Loss History: Total number of claims in the past 3 years*
If More Than One Location List Name/Address For Each Below:
General Underwriting Information

Complete all questions, for each location. Attach separate sheet as needed.
LocalCentral:
LocalCentral:
YesNo
YesNoI Don't Know. Please Advise Me.
YesNo
YesNo
Are there the following on the premises – check all that apply:
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If no, who checks certificates:
YesNo
YesNo
If yes, describe:
YesNo
YesNo
YesNo
YesNo
YesNo;
YesNo
Business Owners Package Coverage – Property & Liability
Distance to nearest Fire Hydrant (feet):*
Nearest Fire Station (miles):*
OwnerTenant
Hours of Operation: *
Year Built*
Number of Stories*
Total Sq Feet of Building*
Sq Feet Occupied by Insured*
Portion of building unoccupied or vacant %*
FrameJoisted MasonryFire ResistiveNon-CombustibleNon-Combustible Masonry
Year of last update: Electric*
Year of last update: Heating/AC*
Year of last update: Plumbing*
Year of last update: Roof*
YesNo
List other businesses adjacent to yours in the same building?
Building Replacement Cost at 100% to value*
Business Personal Property Replacement Cost at 100% to value*
Tenant’s Improvements and Betterments Replacement Cost at 100% to value*
YesNo
if yes, describe*
Location Options and Coverages
$50,000$75,000$100,000
Projected sales over next 12 month at this location: FOOD*
Projected sales over next 12 month at this location: LIQUOR*
Policy Level - Options and Coverages
$1,000,000 per occurrence/$2,000,000 aggregate$2,000,000 per occurrence/$4,000,000 aggregateNot Sure. Please Advise Me.
YesNo
YesNo
YesNo
# of Full Time Employees (35hrs+ per week)*
# of Part Time Employees (under 35hrs per week)*
Location Level - Options and Coverages continued
YesNo
YesNo
YesNo
Building Level - Options and Coverages
Additional Interests: (Mortgage, Loss Payee, Additional Insured) – if more than two, provide on separate sheet:
Name*
Interest*
Address*
Name
Interest
Address
RESTAURANT SUPPLEMENT

Attach restaurant supplement for each location
YesNo
If no, please explain below:*
How long has insured been at this location?
YesNo
If no, indicate floor #
YesNo
YesNo
YesNo
YesNo
If yes, Height of Deck*
Seating Capacity*
YesNo
Piano Player, incidental soft music
YesNo
On premisesOff Premises
YesNo
Company autoEmployee autoDelivery service (Uber Eats, Grub Hub etc.)
YesNo
Company autoEmployee autoDelivery service Uber Eats, Grub Hub etc
YesNo
YesNo
Wood burning stoveTandoorHot PotHot StoneTableside Hibachi or cookingOpen Pit BarbequeBBQ TableNone of the aboveOther
YesNo
YesNo
YesNo
YesNoNA
YesNoNA
YesNoNA
YesNoNA
YesNoNA
YesNo
BOP Liquor Liability Supplement
YesNo
YesNo
Name of Association:*
250,000 per person / $500,000 per occurrence / $500,000 aggregate$500,000 per person / $1,000,000 per occurrence / $1,000,000 aggregate$1,000,000 per person / $1,000,000 per occurrence / $2,000,000 aggregateNA
$250,000 / $500,000 / $500,000$500,000 / $1,000,000 / $1,000,000$1,000,000 / $1,000,000 / $2,000,000I decline to purchase Assault & Battery Coverage
Business Sales
NANo EntertainmentDJ with DancingKaraokeDancingPool TablesLive BandsMechanical BullsDance FloorPub CrawlsHappy HourExotic DancingDrinking Games/TournamentsDartOther
Number of Days with live entertainment per week
Name*
YesNoIs there a written alcohol serving policy in place?
Company EmployeesContracted
YesNo
Name of Alcohol Training Program (if applicable):
YesNoNA
YesNoNA
YesNoNA
Citations And / Or Hearings
YesNo
YesNo
Schedule a call with your restaurant & bar insurance advisor below.
Should be Empty:

INSTANTLY REQUEST A QUOTE

General Underwriting Information

Business Owners Package Coverage – Property & Liability

Location Options and Coverages

Policy Level - Options and Coverages

Location Level - Options and Coverages continued

Building Level - Options and Coverages

RESTAURANT SUPPLEMENT

BOP Liquor Liability Supplement

Business Sales

Citations And / Or Hearings