Voodoo Brewing Restaurant Application

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Applicant Information

Applicant Name(Required)

First Last

Email(Required)

Phone

Address of Applicant(Required)

Street Address Address Line 2 City State ZIP Code

Mailing address same as applicant address?(Required)

Yes

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Optional: Speed up your quote by providing additional detailed information

Optional: Speed up your quote by providing additional detailed information?

Owner Information

Are you the Owner?(Required)

Yes

Owner's Name (Principal)(Required)

First Last

Owner's Home Phone #(Required)

Business Phone #(Required)

Owner's Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Current Policy Information

Effective Date(Required)

MM slash DD slash YYYY

Current Company(Required)

Current Premium(Required)

Any policy or coverage declined, cancelled or non-renewed during three prior years?(Required)

Yes

Business Information

Business Type(Required)

Corporation

Partnership

Individual

Other

Applicant is a(Required)

Restaurant

Diner

Tavern

Night Club

Banquet Hall

Fine Dining

Other

# of Years at this Location(Required)

# of Years in Restaurant Business(Required)

List previous experience(Required)

Building Owner Name(Required)

First Last

Building Owner Address(Required)

Street Address Address Line 2 City State ZIP Code

Include Building Owner as Named Insured as interest may appear?(Required)

Yes

Does Applicant Serve Alcohol?(Required)

Yes

Does Applicant Feature Entertainment?(Required)

Yes

Financial Information

Is Owner or Corporation now or ever involved in any of the following?(Required)

Bankruptcies

Foreclosures

Tax Liens

Business Failures

Any Litigations

None of the Above

Please explain:(Required)

Additional Interests

Add Mortgagee?(Required)

Yes

Mortgagee Name(Required)

First Last

Mortgagee Address(Required)

Street Address Address Line 2 City State ZIP Code

Add Additional Insureds?(Required)

Yes

Additional Insureds(Required)

Add Loss Payees?(Required)

Yes

Loss Payees(Required)

Property Section

Building

Building Limit

Co-Ins %

ACV

R/C

Deductible

Contents

Contents Limit

Co-Ins %

ACV

R/C

Deductible

Business Income

Business Income Limit

Contribution or Co-Ins %

Deductible

Business Income ALS(Required)

Yes

Business Income with Extra Expense(Required)

Yes

Caus of Loss(Required)

Basic

Special

Special with Theft on Contents Only

Loss of Rents

Loss of Rents Limit

Co-Ins %

Cause of Loss

Deductible

Sign

Sign Limit

Type

Wording

Deductible

Glass Coverage Needed?(Required)

Yes

Glass Coverage Value(Required)

Crime Coverage Form C

Crime Coverage Form C Limit

Deductible

Employee Dishonesty

Employee Dishonesty Limit

Deductible

Other Property Coverages

Multiple Occupancies?(Required)

Yes

Please list multiple occupancies(Required)

Liability Section

General Liability

General Liability Limit

Aggregate

Liquor Liability

Liquor Liability Limit

Aggregate

Food Receipts $

Liquor Receipts $

Other Receipts $

Receipts Total

Total Building Square Footage

Restaurant Square Footage

Apartments Square Footage

# of Apartments

Does this business have any of the following? Check all that apply.

Off Premise Parking

On or Off Premise Catering / Banquet

Lodging Operations Other than Apartments

Any Other On or Off Premise Exposures NOT Listed Above

Non-Owned Automobile

Valet Parking

Elevators or Stairs on Premise

Tableside Cooking

Off Premise Parking Square Footage

Off Premise Parking Address

Street Address Address Line 2 City State ZIP Code

Describe Catering Operation

Describe Lodging Operation

Describe Other On or Off Premise Exposures

Are Non-Owned Automobiles Used for Any Deliveries?(Required)

Yes

Number of Employees Using Non-Owned Automobile(Required)

Is Garage Keeper Liability Required?(Required)

Yes

Garage Keeper Liability(Required)

Garage Keeper Liability Limit

Deductible

Liquor Legal Liability Information

Check all that apply to Applicant(Required)

Applicant has liquor license

Applicant sells package goods

Employees are given liquor training

Applicant has written policy on serving alcohol for employees & customers

There is a Happy Hour

Reduced price drinks

A Last Call is given

Shots are given

Shots specials / Shooter girls

Service bar only

None of these apply

Liquor license type and #(Required)

% of Liquor Receipts(Required)

Describe the type of Liquor Training your staff received and when they were trained(Required)

Iment Notified Prior to Shutting Off Patrons?(Required)

Yes

Is Documentation Kept on Each Incident?(Required)

Yes

What time is Last Call given?(Required)

Hours

Minutes

AM/PM

# of Bartenders(Required)

# of Waiters/Waitresses(Required)

Average Length of Employment(Required)

# of Bars on Premises(Required)

Is there a steady bar clientel?(Required)

Yes

Have there been any liquor board violations?(Required)

Yes

Please list ALL violations(Required)

Entertainment Section

Which nights of the week feature entertainment?(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Type(s) of entertainment(Required)

Rock Group

Band (Any Kind)

Go-Go

Other

Please describe the Other type of entertainment(Required)

Age of Clientel(Required)

Does the establishment have any of the following?(Required)

Dance floor

Permitted dancing

Bouncers or Doormen

Amusement devices (pool tables, TVs, video games, etc.)

None of the above

Square Footage of Dance Floor(Required)

Please explain why you have bouncers or doormen(Required)

Describe the # and types of amusement devices(Required)

Claims Information

Have there been any claims within the last 5 years?(Required)

Yes

What type of claims occurred in the last 5 years?(Required)

Property Claims

General Liability Claims

Liquor Liability Claims

Umbrella Claims

Please list ALL Property Claims by Year(Required)

Please list ALL General Liability Claims by Year(Required)

Please list ALL Liquor Liability Claims by Year(Required)

Please list ALL Umbrella Claims by Year(Required)

Umbrella Information

Limit Requested(Required)

Business Auto Carrier(Required)

Policy #

Premium(Required)

Total # of Vehicles

# of Private Passenger Vehicles

# of Commercial Vehicles

Limit

Employers Liability Carrier

Policy #

Limit

Operations Information

Is Applicant Open Now?(Required)

Yes

Please explain why Applicant is not open(Required)

Hours of Operation(Required)

Opening Time

Closing Time

# Days Per Week

Is Applicant a Seasonal Operation?(Required)

Yes

Please explain nature of Seasonal Operation(Required)

Distance to Ocean or Nearest Body of Water

Physical Plant Information

Age of Building

Construction

# of Stories

Age of Wiring

Age of Plumbing

Age of Heating

Age of Roofing

Select all that are present(Required)

Smoke Detectors

Fire Alarm

Burglar Alarm

Sprinkler System

Kitchen Fire Protection

None of the Above

Type of Smoke Detectors(Required)

Electric Smoke Detectors

Battery Powered Smoke Detectors

Type of Fire alarm(Required)

Type of Burglar Alarm(Required)

Type of Sprinkler System(Required)

Age of Sprinkler System(Required)

Type(s) of Kitchen Fire Protection(Required)

UL-300 Wet Chemical Extinguishing System Serviced every 6mos

Above System Covering All Cooking Surfaces

Automatic Gas or Electric Shut Offs for Cooking

Hood and Filters Cleaned Weekly By Staff

BC Extinguisher Available in Kitchen

Hoods and Ducts Over All Cooking Equipment

Hoods and Ducts Maintenance Contract Schedule

None of the Above

Hoods and Ducts Maintenance Contract Schedule: # Month(Required)

Sign & Submit

Insured's Signature(Required)

Acknowledgement(Required)

I understand

The signing of this application does not bind the Applicant nor any company to complete the insurance, but it is agreed that the information contained herein shall be the basis of the acceptance of a contract. It is therefore the warranty of the undersigned that the information contained herein is true and correct, and it is hereby understood that the policy will be warranteed based on this information. It is further understood that any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation.

Date(Required)

MM slash DD slash YYYY

Agent

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Salesperson

Phone

Fax

Additional comments

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Voodoo Brewing Restaurant Application

Applicant Information

Owner Information

Current Policy Information

Business Information

Financial Information

Additional Interests

Property Section

Liability Section

Liquor Legal Liability Information

Entertainment Section

Claims Information

Umbrella Information

Operations Information

Physical Plant Information

Sign & Submit

What We Do

Contact & Locations

Liberty