Casey Insurer Services
SMP OL&T Restaurant/Liquor Form
Company:
*
Jencap
DeCotis Insurance - MA
DeCotis Insurance - RI
Johnson & Johnson Insurance
Market Finders Insurance
Jencap/Quaker Special Risk
Safety Insurance
Insured Name:
*
Policy #:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Agency:
*
Inspector's Name:
*
William Bierce
Keith McEachern
Bill Casey
John Frank
Jim McEachern
David Morin
Ashley Freudenthal
Nicole Messier
Charles Lyons
Greg McEachern
Mark Kramer
Rick Mansfield
Gregg Barney
Dick Herman
Matt Bodman
Tyler McQuade
Latania Knights
Kristian Mahaffey
Erick Hartz
Inspection Date:
*
-
Month
-
Day
Year
Date Picker Icon
Met With:
*
Insured
Owner
Property Manager
Tenant
Caretaker
Employee
Friend
Business Partner
Realtor
Contractor
Family Member
Left Open
NO SHOW
Exterior Only
Person you met with
Contact Name:
First Name
Last Name
Contact Information:
Enter phone numbers & email addresses
Type of Risk/Description:
*
Total Square Footage:
*
Area occupied by insured
Total Building Square Footage:
If different than occupied area
Owned Property:
Leave Blank if Tenant Only
Prior Loss:
*
Yes
No
Prior Loss Description:
Click Here For Business Section
Business Section:
Gross Sales:
*
Enter Dollar Amount
Content Value BPP:
*
Enter Dollar Amount
Number of Employees:
*
In Business For:
*
Insured Is:
*
Tenant
Owner
Owns Building Under Separate Entity
Other
Additional Business Information:
Click Here For Occupancy
Occupancy
If multi-unit, enter occupancy for each floor below.
Basement:
List basement occupancy
First Floor:
List 1st floor occupancy
Second Floor:
List 2nd floor occupancy
Third Floor:
List 3rd floor occupancy
Fourth Floor:
List 4th floor occupancy
Other
Area/Type of Neighborhood
Area
Type of Neighborhood
*
Residential
Commercial
Industrial
Area
*
Urban
Suburban
Rural
Area Security/Safety
*
Good
Fair
Poor
Click Here For Construction
Construction
Age of Building:
*
120 Years Old
# of Stories:
*
1
1.5
2
2.5
3
3.5
4
4.5
5
6
7
8
9
10+
Foundation:
*
Concrete
Brick
Stone
Concrete Block
Concrete Slab
Crawl Space
Pylons
Stone Block
Other
Basement Usage:
*
Finished Area
Utilities
Storage
No Basement
Other
Exterior Frame:
*
Wood Frame
Steel Frame
Concrete Block
Brick
Other
Exterior Siding:
*
Vinyl
Wood Clapboard
Wood Shingles
Cement Fiber Clapboard
Brick
Concrete Block
Aluminum
Asbestos Shingles
Asphalt Shingles
Stucco
Steel Sheathing
Other
Roof Type:
*
Flat
Gable
Hip
Mansard
Gambrel
Sloped
Other
Roof Deck:
*
Wood
Steel
Concrete
Other
Roof Covering:
*
Asphalt Shingles
Rubber Membrane
Tar & Gravel
Wood Shake
Slate
Metal
Other
Roof Age:
*
New
Less than one year
1-5 years
5-10 years
10-15 years
15-20 years
20-25 years
25 + years
Unknown/Not Visible
Other
Interior Walls & Ceilings:
*
Wood Frame
Steel Frame
Concrete Block
Brick
Wall Covering:
*
Drywall
Plaster-lath
Wood Paneling
FRP Paneling
Brick
Concrete Block
Other
Ceiling:
*
Drywall
Plaster
Suspended
Wood
Tin
Tile
Exposed/Open
Other
Flooring:
*
Wood Joists
Concrete
Steel Supports
Floor Coverings:
*
Hardwood
Tile
Carpet
Vinyl
Concrete
LVP
Linoleum
Stone
Subflooring
Other
Off Street Parking:
*
No
Yes
Other
Garage:
*
None
Attached 1 Car
Attached 2 Car
Attached 3 Car
Detached 1 Car
Detached 2 Car
Detached 3 Car
One Car Under
Two Car Under
Other
Overall Condition of Building:
*
Excellent
Good
Fair
Poor
Click Here For Utilities
Utilities
Heating/Cooling System(s):
*
Gas Forced Hot Water
Oil Forced Hot Water
Gas Forced Hot Air
Oil Forced Hot Air
Gas Steam
Oil Stem
Gas/Electric HVAC
Electric Baseboard
Electric Wall Monitor
Gas Wall Monitor
Gas Ceiling Unit
Electric Ceiling Unit
Gas on Gas
Gas Parlor Stove
Wood Stove
Pellet Stove
Wood Fireplace
Gas Fireplace
Gas Radiant
Electric Split Air System
Gas Hydro-Air System
Central Air Conditiong
No Heat
No Access
Other
No. Heating Units:
*
None
One
Two
Three
Four
Multiple
Unknown
Type of Plumbing:
*
Copper
Cast Iron
PVC
PEX
Flex Pipe
ABS
Brass
No Access
Electrical:
*
Breakers
Fuses
No Access
Amperage:
*
60
100
125
200
400
No Access
Other
No. Electrical Panels:
*
No Access
Multiple
One
Two
Three
Four
Five
Electrical Wiring:
*
Romex
BX
Cloth Romex
MC
Commercial Cable
No Access
Other
Active Knob & Tube:
*
No
No Interior Access
Yes
Other
Utility Updates
Heating:
*
New
Within 5 Years
Within 10 Years
Within 15 Years
Within 20 Years
Within 30 Years
Original
Updating During Renovations
No Access
Other
Heating (System 2):
New
Within 5 Years
Within 10 Years
Within 15 Years
Within 20 Years
Within 30 Years
Original
Updating During Renovations
No Access
Other
Heating (System 3):
New
Within 5 Years
Within 10 Years
Within 15 Years
Within 20 Years
Within 30 Years
Original
Updating During Renovations
No Access
Other
Heating (System 4):
New
Within 5 Years
Within 10 Years
Within 15 Years
Within 20 Years
Within 30 Years
Original
Updating During Renovations
No Access
Other
Plumbing:
*
New
Within 5 Years
Within 10 Years
Within 15 Years
Within 20 Years
Within 30 Years
Original
Updating During Renovations
Partial Updates
No Access
Other
Electrical:
*
New
Within 5 Years
Within 10 Years
Within 15 Years
Within 20 Years
Original
Updating During Renovations
Partial Updates
No Access
Other
Hot Water Tank:
New
Within 5 Years
Within 10 Years
Within 15 Years
Within 20 Years
Original
Tankless
No Access
Other
Septic System:
Yes
No
Unknown
Overall Utility Condition:
*
Good
Fair
Poor
N/A
Utility Hazards:
*
Yes
No
Click Here For Protection
Protective Measures
Building:
*
Hardwired Smoke Detectors
Hardwired Carbon Monoxide Detectors
Heat Detectors
Battery Smoke Detectors
Battery Carbon Monoxide Detectors
Plug-In Carbon Monoxide Detectors
Wet Sprinkler System
Dry Sprinkler System
Emergency Lighting
Illuminated Exit Signs
Exit Bars on Doors
Strobes
Klaxons
Fire Pull Stations
Video Surveillance
Security Grates
Fire Escape
No Common Areas
No Interior Access
Other
Additional Protective Measures:
Fire Extinguisher:
ABC
K-Class
Tagged
Other
Sprinkler System
Up-To-Date
Not Up-To-Date
No Tag
Other
Alarms:
Central Station Fire
Internal Fire
Fire Alarm Panel (normal operations)
Fire Alarm Panel (trouble with system)
No Access to Fire Panel
Central Station Burglar
Internal Burglar
None
Other
Fire Hydrant:
*
Within 50 Feet
Within 100 Feet
Within 200 Feet
Within 500 Feet
None
Suction Point
Fire Department:
*
Paid
Volunteer
Within 500 Feet
Within 1 Mile
Within 2 Miles
Within 3 Miles
Within 5 Miles
None
Other
Click to For Restaurant Supplement
Seating Capacity:
*
Does the Insured Provide Table Service:
*
Yes
No
Other
Does The Insured Serve Alcohol:
*
Yes
No
Other
Alcohol vs Food:
*
Enter % Ex. (75% food 25% Liquor)
Does the Insured Provide Live Entertainment:
*
Yes
No
Occasionally
Weekends Only
Other
Type of Food Served:
*
American Pub Food
Italian
Spanish
Seafood
Asian
Thai
Chinese
Korean BBQ
German
Jamaican
Mexican
Indian
BBQ
Pizza/Sandwiches
Other
Kitchen Equipment:
*
Open Flame Grill
Grill
Convection Oven
Pizza Oven
Oven
Deep Fat Fryer
Broiler
Woks
Pork Upright Oven
Other
All Cooking Areas Covered With Hood & Duct System:
*
Yes
No
Other
Hood & Duct Equipped With Filters:
*
Yes, Baffle Filters
Yes, Mesh Filters
No
Other
Hood Serviced By:
*
Company Name and City / State
Hood Serviced:
*
Every Three Months
Every Six Months
Yearly
Not Tagged
Other
Date Last Serviced:
*
Enter Month and Year
Hood & Duct System Equipped With Fire Suppression System:
*
Yes
No
Other
Suppression System Serviced By:
*
Enter Company Name and City/State
Suppression System Serviced:
*
Every Three Months
Every Six Months
Yearly
Not Tagged
Other
Suppression System Date Serviced:
*
Enter Month and Year
Additional Protection:
*
ABC Fire Extinguishers
K-Class Fire Extinguishers
Up-To-Date Service Tag
Not Tagged
Other
Kitchen Has Good Housekeeping:
*
Yes
No
Other
Hazards & Recommendations:
Yes
No
Click Here For Liquor Liability
Does the risk serve alcohol:
*
Yes
No
Other
Type of Establishment:
Restaurant
Bar/Tavern
Hotel Restaurant
Package Store
Convenience Store
Grocery Store
Other
If restaurant, any catering services provided that include alcohol sales:
Yes
No
Other
Business Hours of Operation:
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
Hours:
Maximum Occupancy:
Number of Servers:
Have all servers been trained through approved server training course:
Yes
TIPS
TOPS
TAMS
NO
Other
How often re-certified:
Every Three Years
Every Year
Every Two Years
Not Required
Other
Percentage of Wait Staff Age:
Under 25
25-30
Over 30
Enter Percentage
How often do managers review liquor liability laws with employees:
Daily
Weekly
Monthly
Every Few Months
Yearly
As Needed
Other
Are employees allowed to drink at the establishment:
Yes
No
Occasionally
Other
How is age of customer verified:
Government Issued Picture ID card
Other
I.D. Scanner Used:
Yes
No
Other
Type of Clientele:
Area Workers
Area Residents
Tourists
College Students
Other
Percent of Clientele Age:
Under 25
25-30
Over 30
Percentage
Is the risk located near a college campus:
Yes
No
Is the risk located near a boat dock or marina:
Yes
No
Is there a pool exposure:
Yes
No
Other
Any Drink Specials:
Yes
No
Other
Security Activities:
Bouncer
Contracted Security Firm
Police Officer
Video Surveillance
Other
Firearms stored on premises:
No
Yes
Other
Click Here If Vacant
Vacant, Locked & Secure:
Yes
No
How Often Checked:
Daily
Multiple Times Per Week
Weekly
Bi-Weekly
Monthly
Every 2-3 Months
Other
Utilities Being Maintained:
Electric On
Plumbing On
Heating On
Electric Off
Plumbing Off
Heating Off
Winterized
Other
Under Renovation:
Yes
No
Type of Renovations:
Exterior Siding
Roofing
Windows
Interior Walls/Ceilings
Flooring
Kitchen
Baths
Heating Updates
Electrical Updates
Plumbing Updates
Adding Second Story
Decks
Adding Garage
Cosmetics
Full Rehab
Other
Start Date:
Example: May 2019
Completion Date:
Example: May 2019
Project Costs:
Example: $25,000
Plans for Risk Upon Completion:
Sell
Rent
Primary Residence
Not Sure
Click Here For Exposures
Exposures
LEFT EXPOSURE
No. Feet:
*
Abuts
Attached
Within 5 feet
Within 15 feet
Within 25 feet
Within 50 feet
Within 100 feet
Within 200 feet
Within 300 feet
Within 500 feet
Occupancy:
*
Single Family
Two Family
Multi-Family
Apartment Building
Mixed Use
Commercial Building
Commercial Unit
Wooded Area
Vacant Land
Pond
Lake
Park
Playground
Other
RIGHT EXPOSURE
No. Feet:
*
Abuts
Attached
Within 5 feet
Within 15 feet
Within 25 feet
Within 50 feet
Within 100 feet
Within 200 feet
Within 300 feet
Within 500 feet
Occupancy:
*
Single Family
Two Family
Multi-Family
Apartment Building
Mixed Use
Commercial Building
Commercial Unit
Wooded Area
Vacant Land
Pond
Lake
Park
Playground
Other
REAR EXPOSURE
No. Feet:
*
Abuts
Attached
Within 5 feet
Within 15 feet
Within 25 feet
Within 50 feet
Within 100 feet
Within 200 feet
Within 300 feet
Within 500 feet
Occupancy:
*
Single Family
Two Family
Multi-Family
Apartment Building
Mixed Use
Commercial Building
Commercial Unit
Wooded Area
Vacant Land
Pond
Lake
Park
Playground
Other
Click Here To List Hazards
Hazards & Recommendations
HAZARDS & RECOMMENDATIONS:
*
Yes- See below.
None
Hazard 2025-01:
Recommendation:
Hazard One Photo:
Browse Files
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of
Hazard 2025-02:
Recommendation:
Hazard Two Photo:
Browse Files
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of
Hazard 2025-03:
Recommendation:
Hazard Three Photo:
Browse Files
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of
Hazard 2025-04:
Recommendation:
Hazard Four Photo
Browse Files
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of
Hazard 2025-05:
Recommendation:
Hazard Five Photo:
Browse Files
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of
Hazard 2025-06:
Recommendation:
Hazard Six Photo
Browse Files
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of
Additional Hazards/Concerns:
Additional Hazard Photos:
Browse Files
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of
Click Here To Upload Photos
Exterior Front Pictures:
Browse Files
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of
Exterior Side:
Browse Files
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of
Exterior Rear:
Browse Files
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of
Roof:
Browse Files
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of
Interior Pictures:
Browse Files
Include interior photos of risk
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of
Heating & Cooling Pictures:
Browse Files
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of
Electrical System:
Browse Files
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of
Hot Water Heater:
Browse Files
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of
Additional Utility Pictures:
Browse Files
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of
Protective Measure Photos:
Browse Files
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of
Sprinkler System Photo:
Browse Files
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of
Kitchen Photos:
Browse Files
Include Pictures of Service Tags
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of
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