Thomson Smith & Leach

This Certificate of Insurance Request Form is for existing clients of our agency who hold Commercial policies. Please provide as much information possible for us to process your request. This information will be kept stricktly confidential and will be used for these purposes only.

Resturant Quote

General Information
Name of Business:
Contact Name:
Mailing Address:
City:	State: Zip:
Business Phone:	Fax:
Best Time To Call:	AM PM
Contact Email Address:

About Your Business

Location Address
(if different):

City:

State: Zip:

Type of Risk:

Fine Dining	Family Style	Fast Food	Diner
Bar/Tavern	Go-Go Bar	Nightclub
Other:

Business Structure:

Individual Corporation Partnership Joint Venture
Other:

Federal Tax ID#:

Is this restaurant part of a franchise?:

Yes No
If Yes, name o f Parent Company:

Mortgagee:

Mortgagee Interest:

Additional Insured:

Additional Insured Interest:

Effective Date Requested:

Expiration Date:

Coverages
Please Select Coverages
General Liability Liquor Liability Commercial Property Workers Comp Umbrella Coverage Hired Non-owned Auto

Property Limits & Deductibles
Building (90%) AC	Broad Form	$
Contents (90%) Replacement Value	Special Form	$
Business Income	%	$
	Per Claim Deductible
Liability Limits & Deductibles
General Aggregate	$
Products/Completed Operations Aggregate	$
Per Occurrence	$
Medical Payments	$
Fire Damage	$
Liquor Liability	$
Optional Coverages / Limits & Deductibles
Sign	$	Limits In/Out
Glass	$	Square Footage
Money/Secs	$	Limits In/Out
Food Spoilage	$	Limits In/Out
Other

Underwriting Information
PROPERTY
Building Information
Total Square Feet		Kitchen Square Feet		Dining Square Feet

Year Built		Year Wiring Updated	Electrical in Conduit	Circuit Breakers	Fuse Box
			Y N	Y N	Y N
Plumbing up to Code		Year Plumbing Updated		Year Heating Updated	Year Roof Updated
Y N
Building Condition		Construction Type		# of Stories	Building Code Violations
					Y N
What is Right Exposure		What is Left Exposure		What is Rear Exposure

Free Standing		Other Occupancies		Distance to Nearest Fire Hydrant
Y N
If adjacent business is a restaurant, does it have automatic extinguishing devices?			Is any portion of the building vacant, unoccupied, or seasonal? (If yes, explain)
Y N			Y N
Kitchen Information
Please indicate how many of the following:

Fryers		Ovens		Ranges
Microwaves		Stove Top Burners		Slicers

Grease Cooking	Are ducts, hoods, grease filters and surface cooking areas (including deep fat fryers) protected by a U.S. listed automatic fire extinguishing system?			Is such a system professionally inspected and serviced every 6 months?
Y N	Y N			Y N
Exhaust filters are cleaned	Is there a professional flue cleaning service used on quarterly contract?
	Y N By: Phone Number:
Deep Fat Fryers	Automatic Shut Off	High Limit Switch	Non-Slip Floors	Other Kitchen Safety Precautions
	Y N	Y N	Y N
Exterminator Contracted	Name of Exterminator (if "Yes")	Fire Suppression System
		System Installed On Location	Wet / Dry	Name of Suppression System	Extinquisher Type
Y N		Y N	Wet Dry

Underwriting Information
LIABILITY
Entertainment
Live Entertainment	# of Players	Kind of Music	How Many Nights
Y N
Dancing	Disco	Dance Floor	# of Game Machines
Y N	Y N	Y N

Underwriting Information
CRIME
Bank Deposits Made Daily		Name of Bank
Y N
Safe Class	Type of Locks	Maximum Cash in Register	Maximum Cash on Premises
		$	$
Alarm	# of Alarms	Name of Alarm Company
		Ph#:
Motion Detectors		Any weapons on premises
Y N How often checked:		Y N If yes, explain:

Underwriting Information
GENERAL
How long at this location	How long in this type business	Operated by Owner	Own Other Restaurants	TableService	Self Service	Any Delivery
		Y N	Y N	Y N	Y N	Y N
Hours Open		Days Closed	# of Employees		Estimated Annual Payroll	Neighborhood
From to
Ever suffered earthquake damage	Type of food served on premises		Flaming Drinks		Happy Hours	Written policy for serving minors/ intoxicated patrons
Y N			Y N		Y N	Y N
Exits properly marked	Alternate Access	Security Guards	Parking areas adequately lit/maintained		Separate cigarette butt containers	Designated Smoking Areas
Y N	Y N	Y N	Y N		Y N	Y N
Dart Boards	Mechanical Devices	Prior problems requiring police			Any Liquor Violations
Y N	Y N	Y N If yes:			Y N If yes:

Underwriting Information
FINANCIALS
Total Sales Receipts			Food Sales Receipts		Liquor Sales Receipts
This Year	Last Year		This Year	Last Year	This Year		Last Year
$	$		$	$	$		$
Food Costs				Liquor Costs
This Year		Last Year		This Year		Last Year
$		$		$		$
Estimated Full Time Payroll			Estimated Part Time Payroll		Estimated Owners/Officers Payroll
This Year	Last Year		This Year	Last Year	This Year		Last Year
$	$		$	$	$		$

Loss History

Current / Previous Insurance Company:

Policy Number:

Expires:

Has any carrier cancelled or refused insurance to this applicant:

Y N If yes:

Please describe any losses during the past three (3) years

Date of Loss:	Amount:	Description of Loss:
	$
	$
	$
	$
	$

Additional Comments

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