Name of Business:

DBA:

MAILING ADDRESS
Street:

City:

State:      Zip:
  

RESTAURANT / BAR / TAVERN ADDRESS (if different from above)
Street:

City:

State:      Zip:
  

TYPE OF ESTABLISHEMENT

	Restaurant		Diner
	Tavern / Bar		24 Hr. Diner
	Night Club		Hotel/Motel
	Pizza Parlor		Dinner House
	Country Club		Banquet Hall
	OTHER > > >

OPERATION INFORMATION
Entertainment
Liquor

Number of years in Restaurant Business:
Number of years at Present Location:
Number of years as Owner:
Is Owner/Mng on premises at all times:
Total Number of Employees (Full-time/Pt-Time):
Seating Capacity:

BUILDING INFORMATION:
Frame       Fire Resistive
Brick
Sprinkler   Central Station Alarm
Building Owner

Building Value:

Personal Property (contents):

FINANCIAL INFORMATION:
Annual Food Sales:

Annual Liquor Sales:

CURRENT INSURANCE INFORMATION:
Current Insurer:

Business Income Limit :

Policy Expiration Date:

Current Premium:

Losses within last 5 years - Please Describe:

CONTACT INFORMATION
First Name:

Last Name:

*Email:

Phone:                        Fax:
  

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