R.R.I.S. Restaurant Questionnaire                 

Please provide the following information:    

Referral Agent

(The Referral Agent is the name of your Insurance Agent in our office or how you became aware of our website)

First Name
Last Name
Title
DBA
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
FEIN #
Work Phone
Home Phone
FAX
E-mail
URL

Restaurant Program - Supplemental Application

Date:

1.  DBA: 2.  Risk Location: 3.  Owner's Restaurant Experience: Years (total)     Years (this location) 4.  The Owner is: Manager Cook Investor Other: 5.  Did any prior carrier: Cancel Non-Renew? If so, explain: 6.  Restaurant is: Fast Food Table Service Other: 7.  Hours Open: to 8.  Building Construction is: Frame/Stucco Masonry Other: 9.  Roof Construction is: Tile/Composition Wood/Shake Other: 10.  Building Age: years.   If older than 25 years, when was plumbing and wiring brought up to code? 11.  Building Sprinklered? No Fully Partially (explain): 12.  Burglar Alarm? No Yes Local Central 13.  Parking Lot: Owned/Occupied by Insured Shared with Shopping Center Valet Parking   Other: 14.  Immediate Neighbors   Left:       Dist. Apart:   Right:       Dist. Apart:   Rear:       Dist. Apart: 15.  Are there any residentials (e.g. apartments) in this building? Yes    No.   If "yes," please explain: 16.  Total restaurant area:     Customer area: 17.  Restaurant has: Full Bar    Beer/Wine    None 18.  Delivery: Yes    No 19.  Entertainment: None    Yes, Describe: 20.  Any Dancing? No    Yes, Describe: 21.  Do you employ or use bouncers or security guards? None    Yes, Describe: 22.  Annual Gross Receipts: Food     Liquor 23.  Will restaurant be closed for remodeling/building construction work during the policy period? No    Yes, explain: 24.  Any Cooking at tables? No    Yes, explain: 25.  Any Outside Catering? No    Yes 26.  Are customers allowed access to kitchen facilities? No    Yes, explain: 27.  a)  Is there an automatic suppression system (such as Ansul, Kidde, or other) with an automatic fuel cut-off protecting all cooking areas? No    Yes   b)  Name of installing/Servicing Company:   c)  Does the insured maintain a contract with a professional flue cleaning service? No    Yes   Name of Service:   d)  Are hoods and ducts cleaned at least once every three (3) months? No    Yes   Name of Service:   e)  How often are filters cleaned? 28.  Fire Extinguishers   a)  Are the fire extinguishers serviced and recharged every 12 months? No    Yes   Name of Service:   b)  Date last serviced and recharged:   c)  Number of extinguishers: In cooking area    BC Type       In customer area    BC Type   Answers to questions 27 and 28 will become a part of the policy and will serve as warranty to the policy as described below:   In consideration of the premium at which this policy is written based upon the protection of the premises by protective safegaurd systems and services described under 26 and 27 above, it is warranted that answers to questions 26 and 27 are accurate to the Insured's best knowledge and that the Insured shall exercise due diligence in maintaining all equipment in complete working order and service contracts uninterupted. The Insured will give immediate notice of any impairment or suspension of such equipment or services, to this company.     Applicant's Signature: ______________________________________________Date: _____________

Ritchie & Rose Insurance Services, Inc.
Bus  (530) 365-4705   Fax (866) 885-1428   DOI License No.  0F44143