Restaurant Insurance Step 1 of 4 25% Name of Insured:(Required) First Last Date of Birth:(Required) MM slash DD slash YYYY Phone Number:(Required)Email Address:(Required) Name of Restaurant:(Required)Mailing Address:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Restaurant Address:(Required) Same as Mailing Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Type of Restaurant:(Required)Select OneFast FoodBuffetCasual/Family DiningTake-Out OnlyCafeteriaFine DiningCooking at your Table, such as BBQBar/Tavern/NightclubConcessionaire/Food TruckCateringOpening Time of Operation:(Required) Hours : Minutes AM PM AM/PM Closing Time of Operation:(Required) Hours : Minutes AM PM AM/PM Gross Sales:(Required)Food Sales:(Required)Liquor Sales(If none, Please put a Zero in this Field):(Required)Other Sales(if none, Please put a Zero in this Field):(Required)Does the Applicant have Liquor Liability in Force:(Required)Select OneYesNoTotal Seating Capacity:(Required)Is there any Table Service:(Required)Select OneYesNoDoes this Applicant rent out Spaces for Private Events, such as Weddings or Parties:(Required)Select OneYesNoWhat is the Square Footage of the Rental Space?:(Required)Sales Generated from Renting the Space Out:(Required)Is There a Grill?:(Required)Select OneYesNoIs there a Grease Chute for the Grill?:(Required)Select OneYesNoHow often is the Grease Chute Cleaned?:(Required)Select OneWeeklyMonthlyQuarterlySemi-AnnuallyAnnuallyAre There Deep Fat Fryers?:(Required)Select OneYesNoAre Deep fat Fryers Located more than 16" from an open Flame?:(Required)Select OneYesNoDo Deep Fryers have Thermostats or High Temperature Limits?:(Required)Select OneYesNo Is all Cooking Equipment Located Beneath an Approved Hood/Duct System:(Required)Select OneYesNoHow often are the Hood and Duct Cleaned?:(Required)Select OneDailyWeeklyMonthlyQuarterlySemi-AnnuallyAnnuallyAre the Hood and Duct Cleaned by a Firm?:(Required)Select OneYesNoIs there an Automatic Fuel Shut-Off?:(Required)Select OneYesNoAre there Portable Fire Extinguishers?:(Required)Select OneYesNoNumber Tagged on the Extinguisher:(Required)Date Extinguisher was Tagged:(Required) MM slash DD slash YYYY How Often are Refrigerator Compressors Inspected and Serviced?:(Required)Select OneDailyWeeklyMonthlyQuarterlySemi-AnnuallyAnnuallyAre There at Least 2 Means of Egress (Emergency Exits) from the Restaurant?:(Required)Select OneYesNoIs there a Fire Alarm?:(Required)Select OneYesNoIs there a Burglar Alarm?:(Required)Select OneYesNoIs there a Delivery Service?:(Required)Select OneYesNoDelivery Service is Done by:(Required)Select OneEmployees of the InsuredOutside of Independent Firms(UberEats, DoorDash):How is the Delivery Service Carried Out?:(Required)Select OneBicycleCarOtherIf Other, Please Explain Here:(Required)If you Offer a Catering Service, is it:(Required)Select OneOn PremisesOff PremisesI do not have a Catering ServiceWhat Procedures/Precautions are Taken to Prevent Food Borne Illnesses?:(Required) Washing Hands Thoroughly Allergy Procedures Separating Foods of Different Types Cooking to the Proper Temperature Refrigerating Good Promptly Ensuring Clean Stations/Dishes/Utensils Use of Safe Water Reheat Cooked Foods Thoroughly Use of Hairnets Use of Gloves Other/Not Listed Has the Listed Applicant ever been Cited for any type of Health Code Violations?:(Required)Select OneYesNoOther Procedures or Precautions Taken to Prevent Food Borne Illnesses:(Required) Add RemovePlease Provide Citation or Incident Details:(Required)What Controls are in Place to Avoid Over-Serving of Alcohol or Distribution to Minors?:(Required) RCS Training ID Verification Training Stamp/Sticker System Drink Counting System Portion Control Tools Other/Not Listed Do Bartenders have TIPS(Training for Intervention Procedures) Training:(Required)Select OneYesNoOther Procedures or Precautions Taken to Avoid Over-Serving of Alcohol or Distribution to Minors:(Required) Add RemoveHas the Applicant been Cited for Violations of Beverage Laws?:(Required)Select OneYesNoPlease Provide Citation or Incident Details:(Required)Please Indicate any Entertainment Provided:(Required) Live Music Dance Floor Karaoke Arcade Games Amusement Devices Other None of the Above Please Provide Details about any Amusement Devices:(Required)Please Provide Details of any Other Types Entertainment:(Required)Is There a Valet Parking Service?:(Required)Select OneYesNoIs There a Separate Insurance for the Valet Parking Exposure?:(Required)Select OneYesNoAre any Bouncers/Security Personnel Employed or Contracted?:(Required)Select OneYesNoAre all Employee's References Checked Prior to Hiring?:(Required)Select OneYesNo Please Upload any Declaration Pages, Inspection Results, and any Other Important Documents here:File(s) Drop files here or Select files Max. file size: 98 MB. 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