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Chapter 7 Bankruptcy Worksheet, Arizona by qaw17439


Chapter 7 Bankruptcy Worksheet, Arizona document sample

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									                                                      STATEWIDE INSURANCE CORP.
                                                    P.O. Box 30527, Phoenix, Arizona 85046

                                                              NEW MEXICO
                                                         BAR & TAVERN PROGRAM
                                                      COLONY INSURANCE COMPANY

Insured:                                                           Policy #:
Effective:                                                         Agency:

Is this business a New Venture?

Has this insured been claim free with Statewide for more than one year?
                                                                                   PREMIUM MODIFIER =            1.00

TO SUBMIT ANY RISK, PLEASE USE THE ACORD APPLICATION.                                                                 Rates effective 06/15/07
                                           GENERAL LIABILITY

Restaurant Location?                                                               Where is the Restaurant Located?
Liability Limit Requested?                                                         Please select Limit of Liability
Do you want a Double Aggregate?                                                                                                  1.00
Aggregate Limit
Deductible Requested?                                                              Please select Deductible
Total Receipts - Location 1?                                                       What are the TOTAL receipts for Location 1?
Liquor Receipts - Location 1?
Total Receipts - Location 2?                                                       What are the TOTAL receipts for Location 2?
Liquor Receipts - Location 2?
Does Location 1 have a Dance Floor?
Does Location 2 have a Dance Floor?
# of Additional Insureds Requested?

   Loc. #          Class Code            Receipts    Base Rate       Agg. Factor   Ded. Factor     Modifier   Final Rate     Premium
     1                  0                  $0
     2                  0                  $0

                                                                                             TOTAL GL PREMIUM                     $0

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                     Protection Class Factors                                                  Deductible Factors
    1-6                7             8                 9-10                           $500          $1,000        $2,500
    1.00              1.20          1.50              Submit                           1.20           1.00         0.97

                         Coverage Factors                                                     Construction Factors
   Basic              Broad    Spec'l - No Theft   Special + Theft                   Frame          Masonry        N/C
   0.94                0.98         0.99               1.00                           1.00           0.91          0.91

                                                                                    Rating Factor
Type of Coverage Desired?                                                               1.00        Please Select Coverage Type
Deductible Requested?                                                                   1.00        Please Select Deductible
Protection Class?                                                                       1.00        Please Select Protection Class
Building Construction?                                                                  1.00        Please Select Construction Type

 Location #                 Description             Base Rate               Limit   Rate Factor       Modifier    Final Rate    Premium

                                                                                        TOTAL PROPERTY PREMIUM                       $0

    /74dd33e4-004b-4fa8-bd54-cbcb9fc51e94.xls                        Page 2 of 5                                           Revision 06/07
                                               OPTIONAL PROPERTY COVERAGES AVAILABLE

             Do you want Property Enhancement Coverage?                                                                         $0

                                                            Coverage Includes ALL of the following:
                                             Description                             Limit                    Deductible
                                         Accounts Receivable                        $5,000                      $250
                                        Electronic Data (EDP)                       $5,000                      $250
                                        Employee Dishonesty                         $5,000                      $250
                                      Fire Dept. Service Charge                     $5,000                      $250
                                      Fire Suppression System                       $5,000                      $250
                                            Food Spoilage                           $5,000                      $250
                                          Money & Securities                        $1,000                      $250
                                     Personal Effects of Others                     $5,000                      $250
                                       Tenant Glass Coverage                        $5,000                      $250
                                     Valuable Papers & Records                      $5,000                      $250
                                            Sign Coverage                           $5,000                      $250
                                           Outdoor Property                      $5,000 Agg.                    $250
                                       Security Guard Expense                    $1,000 Agg.                    $250
                                         Perimeter Extension                      1,000 feet                    $250

             Do you want Crime Coverage?                                                                                          $0

                                                                       Coverage Includes:
                                            Theft of Money or Securities Inside & Outside the Premises        Deductible
                                                                   $5,000 Limit                                 $250

                                                                             TOTAL OPTIONAL COVERAGES PREMIUM                     $0

                                                                                                      Premium Summary

                                                                                   General Liability                             $0
                 Terrorism Premium                                                 Property                                      $0
                         $0                                                        Optional Property                             $0
                                                                                   Additional Insureds                           $0
             Accept Terrorism?                                                     Premium Sub-Total                             $0
             Is Terrorism Coverage Desired?                                        Policy Fee                                    $0
                                                                                   Terrorism Premium                             $0
                                                                                   Taxes / Fees                                 $0.00
                           Print Rating Worksheet and
                               Proceed to Page 2 -
                            Supplemental Application                               TOTAL CHARGES                                $0.00

/74dd33e4-004b-4fa8-bd54-cbcb9fc51e94.xls                           Page 3 of 5                                         Revision 06/07
                                    TAVERN / BAR - SUPPLEMENTAL APPLICATION

Agency Name:
Applicant Name:
Applicant's Web Site Address:                                                                       Date:            1/4/11

                                                       GENERAL INFORMATION
Food Receipts:                                         Seating Capacity:
Liquor Receipts:                                       Operating Hours:
Other Receipts:                                        Square Footage of Building:
Total Receipts:                              $0        Yrs. in business at this location:

                                           Type of Establishment - Check ALL that apply
Bar / Tavern
Sports Bar
Nightclub or Private Club
Bring your own liquor facility (BYOB)
Happy Hours for drink specials
Open Barbeque Pits
Raw seafood served

                                                         Applicant Information
Are the owners active in the business?
Number of years experience?
Has applicant filed Bankruptcy (Chapter 7, 11 or 13)?
Is applicant currently in receivership?

                                                      Miscellaneous Information
Are there any apartments in the building?

                                                           Cooking Exposure
           Complete if Property coverage is requested (check the appropriate box)                   Yes                No
Do they have an automatic fire extinguishing system that protects hoods and cooking surfaces
including deep fat fryers?
Does the fire extinguishing system have a manual release located outside the kitchen?
Are the Exhaust filters, ducts and hoods cleaned by a professional cleaning service quarterly and
inspected annually?
Does the cooking equipment have an automatic fuel shutoff?
Are the deep fat fryers separated from any cooking surface by at least an 18-inch, non-
combustible barrier?
Is there proper disposal of trash and smoking materials?

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                                    TAVERN / BAR - SUPPLEMENTAL APPLICATION

                                      Check the appropriate box                                Yes                No
Is the property, including steps, railings and lighting, in good condition?
Does the building have emergency lighting?
Are there any firearms on the premises?
Does the insured employ bouncers?
Does the insured employ ID checkers?
Does the insured employ or subcontract armed security? If yes, please provide details below:

                   Check the appropriate box                                   Yes     No
Are there bands or DJ's?
Are there pool tables?
Does the insured employ dancers?
Any other entertainment (i.e. mechanical bulls, playground)?

                            Check the appropriate box                                 Yes       No
Is the parking lot under the applicant's control?
Is valet parking provided by your employees?

I hereby certify that all information is accurate to the best of my knowledge:

Applicant Signature:                                                                           Date:

Producer:                                                                                      Date:

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       /74dd33e4-004b-4fa8-bd54-cbcb9fc51e94.xls/Page 2 - Supplemental App 5                           Revsion 06/07

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