Texian Insurance: Quotes: Bar/Restaurant Quote

Belton, Temple, Waco, Round Rock, Killeen & Waco2

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BAR / RESTAURANT QUOTE

Applicant's Name:
Mailing Address:
City State Zip
Phone: Fax:

PROPOSED EFFECTIVE DATE:
From To

Email:

Applicant is: Individual	Corporation	Partnership	Joint Venture
Other (Specify)

LIMITS OF LIABILITY REQUESTED

General Aggregate

Products & Completed Operations Aggregate

Personal & Advertising Injury

Each Occurrence

Fire Damage (any one fire)

Medical Expense (any one person)

$ Excluded

Other Coverages, Restrictions and/or Endorsements

Deductible

Classification of risk:
Tavern	Disco	Bowling Center	Caterer: Off premises On premises
Restaurant	Banquet facility	Membership Club	Country Club

Annual Sales
	Past 12 Months	Next 12 Months
Liquor Sales	$	$
Food Sales	$	$
Other	$	$
Total	$	$

Clientele:
Local Residents	Families		Retirement Community
Median age of patrons:	18-25	25-30	30-40	40 and over
Are premises located near a college or university?

Entertainment:
Is there any live entertainment on premises Yes   No
Number of times per week
If yes, describe (include go-go dancers, topless, disco, exotic):
Is there dancing? Yes   No
Does applicant have amusement devices? Yes   No
If yes, how many?

Describe:

Is there a minimum or cover charge? Yes No

Sports on premises? Yes No If yes, provide complete details:
Sports sponsored off premises? Yes No Number of times per week: Give details:

General Information:
Are facilities available for use or rent for private parties, receptions, banquets or similar affairs? Yes No

If yes, number of times per year:
Describe:

Does applicant advertise or promote "happy hour" or other events when drinks are sold at a lower price than usual? Yes No
Do you subscribe to a taxi or other service providing transportation home to apparently intoxicated patrons? Yes No

If yes, describe:

Number of years under current management:
How many hours per day is applicant open?
Type of meals served: Full Meals Short Order
Maintenance of building is: Good Average Poor
Housekeeping Good Average Poor
Does applicant have parking area? Yes No
Is lot well lit? Yes No
In the past five years, has applicant been cited by the Liquor Control Commission? Yes No

If yes, give date(s) and full explanation:

Are police records and background checks conducted on applicants? Yes No
Number of bouncers or doormen
Are security/bouncers/doormen Employees Independent Contractors
If independent contractors, do they provide Certificates of Insurance and Additional Insured Endorsements to our insured?      Yes No
Does applicant have Workers' Compensation coverage in force? Yes No
Does applicant lease employees? Yes No
During the past 3 years, has any company ever cancelled, declined or refused to issue similar insurance to the applicant?     Yes No

If yes, explain:

Previous Insurance: Indicate premium and losses for past three years. Describe all losses.
Year	Company	Policy #	Premium	Pd Losses	Res Losses	Description

SCHEDULE OF HAZARDS
Loc. No.	Classification	Class. Code	Premium Bases: (a) Gross Sales (p) Payroll (a) Area (c) Total Cost (t) Other	Terr

TRANSITION

1. Has this risk or any location not qualified for transition? Yes No
2. If this risk qualifies for transition, indicate year it first qualified:

Loc. No.	New Class. Code	Previous Basis	Previous Exposure	Applicable Coverage (Premises or Products