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Affordable Health Care Act
 Restaurant Quote 
Restaurant Insurance Quote

Contact Information
Name of Business:
Contact Name:
Address:
City:
State: Zip:
Business Phone:
Fax Number:
Contact Email Address:
Current Insurance Information
Current Insurance Carrier:
Premium: $ Expiration Date:
Your Business Information
Number of years In business under current ownership?
At this location?
Has the owner ever been involved in a bankruptcy or business failure?
YES NO
lf needed, will financial statements be provided prior to binding?
YES NO
What are the gross sales for past 3 years:
Year
Food $
Liquor $
Year
Food $
Liquor $
Year
Food $
Liquor $
What are the hours of operation?
Is the business seasonal?
YES NO
Months of operation:
to
Is there a bar or lounge?
YES NO
If yes, describe
Happy Hour?
YES NO
If liquor is served, describe the training protocol for liquor servers
Is there live entertainment?
YES NO
If yes, describe In Comments section (type, nights per week, hours, etc.).
Is there a dance floor(s)?
YES NO
If yes, what is its size?
Are there any operations away from the premises, such as catering?
YES NO
If yes, explain.
Any tableside cooking or food preparation?
YES NO
Was the building originally built as a restaurant?
YES NO
If no, has wiring, etc., been updated for restaurant occupancy?
YES NO
If Yes, When?
Which floor is the restaurant located on?
Maximum seating capacity of restaurant:
Of lounge
Number of exits:
Are all exits free of obstruction, lighted and marked with exit signs?
YES NO
Is there emergency lighting?
YES NO
Has insured ever been cited by Board of Health?
YES NO
If yes, explain
Housekeeping:
Excellent
Good
Fair
Poor
Valet Parking?
YES NO
Is there a coat check room?
YES NO
Are all areas over ranges grills, fryers, and all other cooking surfaces, and hoods and ducts protected by a ULB00-compliant automatic fire extinguishing system?
YES NO
Is there a maintenance agreement to regularly inspect and service the system?
YES NO
No Times per year
Are the employees trained in the use of the automatic extinguishing system and portable fire extinguishers?
YES NO
Is there a maintenance agreement with an outside firm to clean the hood and duct system?
YES NO
Times per year
If no, explain
How often are the grease filters cleaned by the employees?
Additional Comments
Please give any additional comments or questions

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