Business Entity ---IndividualJoint VenturePartnershipCorporationLLCLLP
Mailing Address if different
Square Footage of Building Occupied
Square Footage of Customer Area
Number of Stories
Building Construction Type
Roof Comp Flat
Year building built
Building Has Automated Ceiling Sprinklers?
Smoke Detectors, Fire Extinguishers, Deadbolts on all Doors?
Parking For Your Customers Only?
If Yes, Number of Parking Spaces You Control
Type of Restaurant ---Fast FoodCasual w/o LoungeCasual w LoungeFine Dining w/o LoungeFine Dining w Lounge
Number of Employees
Payroll of Employees
Total Annual Gross Receipts
Total Annual Alcohol Receipts
Years of Management Experience
Years You Have Owned This Business
Ansul 300 System Used?
Ansul Cleaned Professionally?
Cleaned How Often
6 months 12 months
Catering Away From Premises?
If So, What % of Total Receipts
Central Station Alarm?
Is There Entertainment?
Dance Floor Size (if applicable)
Bouncers, Doormen, ID Checkers, Armed Guards, Security Guards?
If Yes, Number of Each
Are They Employed By You or Hired by an agency
Number of Video Games (Pool Tables)
Number of Video Games (Darts)
Number of Video Games (Other)
Number of Bartenders
Building Coverage Amount if Owned
Contents Coverage Amount
Do You Currently Have Insurance?
Name of Company
Expiration Date or Renewal Date
[date* date-662 id:datepicker]
Losses in Last three Years (Please Describe and Loss Amount)