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Restaurant_Supplemental_Questionnaire

VIEWS: 7 PAGES: 2

									                                            BROKERING AGENT’S REGISTER NUMBER #:
                                            (IMPORTATNT: IN ORDER FOR COVERAGE TO BE BOUND ALL QUESTIONS MUST BE ANSWERD COMPLETELY BEFORE SUBMISSION AND INCLUDE TOTAL NET PREMIUM. IF ADDITIONAL SPACE IS
                                            NEEDED, UNSE ADDITIONAL APPLICATION. COVERAGE MAY ONLY BE BOUND BY THE BROKERING AGENT AFTER RECEIVING TELEPHINIC, ELECTRONIC OR FACSIMIL APPROVAL FROM THE
                                            INSURER.)


                                                                               RESTAURANT SUPPLEMENTAL QUESTIONNAIRE
                                                                                                                            [ ] NEW                  [ ] RENEWAL
                                            Proposed Effective Date:                                              To                          Policy Number:

Applicant/Insured:
DBA:                                                                                                                 Producers Name & Address:

Address:
City & State:                                                             Zip:
Inspection Contact:                                                   Phone:
Accounting Contact:                                                   Phone:                                         Agent’s 2-20 License #:

[ ] Individual                [ ] Partnership                         [ ] Corporation                          [ ] Non-Prof Corp.                          Years in Business:             ___________
Location 1:        Street: ___________________________                    City & State: __________________                        County: ________________                     Zip: _____________
Location 2:        Street: ___________________________                    City & State: __________________                        County: ________________                     Zip: _____________


1.     Type of Restaurant:
2.     Hours of operation:                                                                  Days of operation:
3.     Advise annual Restaurant receipts (Including Liquor Sales):                          $
4.     Total Restaurant area:                                   Sq. Ft.      Area accessible to the public:                                               Sq. Ft.
5.     Is Restaurant located in a common area with other entities?                          [ ] Yes            [ ] No
       Describe:
6.     Any steps or stairs in premises?            [ ] Yes            [ ] No
       Describe:
7.     Does restaurant offer table side cooking?                  [ ] Yes            [ ] No
       If yes, please describe:
8.     Complete table side service?            [ ] Yes            [ ] No
       If no, please describe:
9.     Any catering operations?             [ ] Yes           [ ] No             If yes, advise %                      %
       Away from premises?             [ ] Yes            [ ] No
       If yes, please describe:
10.    Delivery service available?          [ ] Yes           [ ] No             If yes, advise %                      %
       Vehicles owned by Named Insured?                       [ ] Yes            [ ] No
       If no, is proof of coverage required?              [ ] Yes            [ ] No
11.    Bar/Lounge area?           [ ] Yes          [ ] No             If yes, number of seats?
12.    Is alcoholic beverage services limited to same hours of operation as Restaurant?                                    [ ] Yes           [ ] No
       If no, what are the Bars hours of operation?                    Form:                           To:
13.    Happy Hour?           [ ] Yes           [ ] No             If yes:        Form:                             To:
       Any Last Call?        [ ] Yes           [ ] No             If yes:        Form:                             To:
14.    Dancing/Dance Floor?            [ ] Yes            [ ] No
15.    Valet Parking?        [ ] Yes           [ ] No
       If yes, provided by insured or services subcontracted?
       I subcontracted, please describe:
16.    Gift Shop?       [ ] Yes        [ ] No             If yes, advise annual receipts:                  $
17.    Package Store?        [ ] Yes           [ ] No
18.    Electronic Video Games?              [ ] Yes           [ ] No             If yes, amount of gaming machines:
19.    Dart Boards?       [ ] Yes           [ ] No            If yes, are they Velcro tips darts?                     [ ] Yes            [ ] No
20.    Pool/Billiard Tables?        [ ] Yes            [ ] No             If, yes, advise number of tables
21.    Amusements Devices?             [ ] Yes            [ ] No             If yes, advise number of devices:
22.    Water exposure?            [ ] Yes              [ ] No                If yes, what type :
NGIC\SUPPL\REST
Edition 05/05                                                                                                                                                                           Page 1 of 2
23.    Boat Docks?        [ ] Yes          [ ] No
24.    Boat Slips?        [ ] Yes          [ ] No
25.    Open Pit Bar-B-Que?            [ ] Yes              [ ] No
26.    Advise percentage of alcoholic beverage sold?                         %
27.    Total alcohol sales in most recent 12 months:           $
28.    Anticipated alcohol sales for current year:             $
29.    Total food sales in must recent 12 months:          $
30.    Anticipated food sales for current year:            $
31.    Does automatic extinguisher system cover all cooking surfaces including grill, broilers, hood and exhaust duct?               [ ] Yes       [ ] No
       Is there an active service contract for inspection and maintenance of hoods, ducts and automatic extinguishing
32.                                                                                                                                  [ ] Yes       [ ] No
       systems on at least a semi-annual basis>
       Advise last date of service:
33.    How often are hood filters clean?


The following space provided is for description purposes:




Additional Information:
If you answer “Yes” to any of the questions, explain in the “Remarks” box provided below.
1.    Any policy or coverage declined, cancelled or non-renewed during the last 5 years?                 [ ] Yes          [ ] No
2.    Any lawsuits in the past 5 years?          [ ] Yes            [ ] No
3.    Has the applicant and/or directors had any loan defaults in the past 5 years?                [ ] Yes          [ ] No
4.    Has the applicant and/or any employees ever been convicted or forfeit for any criminal violations?                 [ ] Yes          [ ] No
5.    Has the applicant filed any insurance claims in the past two years?            [ ] Yes          [ ] No



Use this space for any necessary explanation. (If more space is needed, use a separate sheet).
Remarks:




I agree that if my down payment or full payment check is uncollectible due to a returned check because of insufficient funds or any other form of dishonored
payment including but not limited to an electronic transaction, coverage will be void or null from inception.

This application is in compliance with Florida Statute 626.752. A copy has been furnished to the applicant or insured and coverage is
( ) Bound Effective 12.01 am _______________ (Date) _______________ (Not Bound)

On this application, Florida Statute 627.409 states: “A misrepresentation, omission, concealment of fact, or incorrect statement may
prevent recovery under the contract or policy…”
Any person who knowingly and with intent to injure, defraud, or deceive any insurer file a statement of claim or an application
containing any false, incomplete or misleading information is guilty of a FELONY of third degree.

I agree and understand that this application will be made part of the policy when issued.
I understand this application is not a binder indicated as such on this form by the Brokering Agent.




       Insured’s Signature                                             Agent’s Signature                                                   Date




NGIC\SUPPL\REST
Edition 05/05                                                                                                                                     Page 2 of 2

								
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