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Name of Restaurant / Bar / Caterer: *

Please fill in your restaurant name.
Name of all Owner(s): *

Please enter name of owner('s).
Your Name: *

Input required.
Business Address
Street: *

Please enter your business street address.
City: *

Please enter your city.		 Province: *

 Postal Code: *

Please enter your business postal code.

Mailing Address (if different from above)
Street:
City:

 Province:

 Postal Code:
Office Phone Number: *

Input required.		 Fax Number:

Input required.
E-mail *

Invalid email address.
Website Address:

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Number of Years in Business: * Please enter a numeric value.
Number of Years at this Location: * Please enter a numeric value.
Is this location Owner Operated?  *Make a selection.
In the past 5 years, have you violated any health or safety codes? * Make a selection.
Annual Receipts Before Tax: * $ Please enter a numeric value.
Liquor / Wine / Beer Receipts: * $ Please enter a numeric value.
Receipts from Other: * $ Please enter a numeric value.
Food Receipts: * $ Please enter a numeric value.
Please decsribe any outside Entertainment / Activities (events, sports, etc.) which you substantially sponsor / operate:
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For each day, please provide the hours of operation:
Monday: *
Please enter a numeric value.		 Friday: *
Please enter a numeric value.
Tuesday: *
Please enter a numeric value.		 Saturday: *
Please enter a numeric value.
Wednesday: *
Please enter a numeric value.		 Sunday: *
Please enter a numeric value.
Thursday: *
Please enter a numeric value.
# of Full Time Staff: *
Please enter a numeric value.		 # of Part Time Staff: *
Please enter a numeric value.
Do you make deliveries? * Make a selection.
Percentage of Sales:
If yes, do you hire independednt contract drivers?
Make a selection.
If yes, do you receive proof of insurance from all drivers?
Make a selection.
Have you ever been fined for a viloation concerning alcohol, or has your liquor license been suspended? *
Make a selection.
If yes, please provide details: Invalid Input
Have all alcohol servers received smartserve training? * Make a selection.
Do you call taxis for intoxicated patrons? * Make a selection.
Do you ever hire bouncers, doormen, or additional security? *
Make a selection.
If you hire security, please provide details: Invalid Input

Entertainment (check all that apply)
Sq. footage:
Number:
Number:
Number:
Enter a number.

Tell Us About Your Premises

Inside Square Footage: *
 


Please enter a numeric value.

   Number of Seats: *
Please enter a numeric value.
Outside Patio: *
Make a selection.		   Number of Seats: *
Please enter a numeric value.
Building Type: *
Invalid Input
Number of Stories *
Invalid Input
Building Materials: *
Invalid Input
Years Built: *
Invalid Input
If over 25 years, please select when the following services were last updated:
Wiring:
Invalid Input
Plumbing:
Invalid Input
Heating:
Invalid Input
Roof:
Invalid Input
Is there a basement? *
Invalid Input		   If yes, drains checked and clear?
Invalid Input

Fire Protection
Fire Hydrant within 100 meters? * Invalid Input
Distance to Fire hall (if located outside city): * Invalid Input
Are your premises protected by a sprinkler system? * Invalid Input
Do you do any deep frying? * Invalid Input

Invalid Input

Security

Do you have a Burglar Alarm? * Invalid Input

Do you have a Fire Alarm? * Invalid Input

If Yes, ULC Approved? Invalid Input

Are your Alarms Monitored? Invalid Input

if Yes, name of monitoring company: Invalid Input

Do you have a safe? * Make a selection.
If Yes, describe the class of safe (shown on inside door):
Invalid Input
Maximum cash on premises overnight: * Invalid Input

Tell Us About Your Insurance

In the past 5 years, has prior insurance coverage ever been declined or canceled? *

Invalid Input

If Yes, provide details: Invalid Input

Claims in the last (5) years? * Input Required.

Date of Loss   Cause   Payment or Reserve


Invalid Input		  
Invalid Input		  
Invalid Input


Invalid Input		  
Invalid Input		  
Invalid Input
Insurer: *
Invalid Input
Policy Term -- From:
Input required.		   To:
Input required.
Premium: $ *
Input required.
 

Please tell us more about your coverage requirements

Coverage (replacement value)

 Limits Required

Deductible *
Selection Required.




Building (if applicable)
Invalid Input

$

Annual rent from tenants *
Invalid Input

$

Contents of Every Description: Equipment / Stock / Computer Equipment Office Equipment / Leasehold Improvements *
Input required.

$

Sign: *
$ value required.

$

Crime Coverage (Cash): *
$ value required.

$

Equipment Breakdown Included / Boiler Machinery *

Included

Business Interruption Limit: *
$ value required.

$

Commercial Liability *
Selection Required.




Umbrella Liability *
Selection Required.



 
Additional Comments: Invalid Input

Your insurance company requires full disclosure of all business operationts that happen during your policy period. If you omit any details, you may void your insurance coverage. If you have any concerns whatsoever, please contact us.
 
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