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CGA Restaurant Insurance Quote Request
We would like to provide you with a free, no-obligation quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Submitting Information
Business Name:
Contact Name:
Street Address:
City:   State:   ZIP:
County:   Email:
Business Phone: Fax:

Application Information Section
Name:
Title:
Business Name:
Street Address:
City:   State:   ZIP:
Type of Corporation:
Email:
Business Phone: Fax:

About Your Business
Location Address (if different):
City:   State:   Zip:
Type of Risk: Restaurant   Tavern   Fast Food   Bar
Other:
Applicant is: Individual   Corporation   Partnership   Joint Venture
Other:
Mortgagee:    Mortgagee Interest:
Additional Insured:    Additional Insured Interest:
Effective Date Requested:    Expiration Date:

Premises Information Section
Location Number:
Location Address:
City:
State:
Zip:

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

Rating Information
Construction Type:
Fire/Protection: Sprinkler       Smoke Detector       Fire Extinguisher
Square Footage: Total       Customer
Food Receipts: $         Liquor Receipts $

Underwriting Information
PROPERTY
Building Information
Age When Rewired Electrical in Conduit Circuit Breakers Fuse Box Plumbing up to Code
Y  N Y  N Y  N Y  N
Building Condition Housekeeping # 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
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

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

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

Underwriting Information
GENERAL
How long at this location How long in this type business Operated by Owner Table Service Self Service Any Delivery
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:


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
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.

 
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