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Restaurant/Tavern Application

Your Name*
Email*
Legal Business Name*
Phone*
Location Address*
Street Address Address Line 2 City State ZIP Code
Is the mailing address the same as the location address?*
- Yes
- No
If No, Please Enter Mailing Address
Street Address Address Line 2 City State ZIP Code
Proposed Effective Date From*
MM slash DD slash YYYY

12:01 AM Standard Time at the Address of the Applicant.
Proposed Effective Date To*
MM slash DD slash YYYY

12:01 AM Standard Time at the Address of the Applicant.
Property Coverage Requested
Building Limit, If Needed ($)
I&B (Permanently Installed Property) ($)
Business Contents Limit ($)
Estimated Gross Annual Business Income ($)
Spoilage Coverage Limit ($)
Refrigeration Maintenance Agreement
- Yes
- No
Liability Coverage Requested
Do you need umbrella coverage?
- Yes
- No
If Yes, please choose coverage amount:
- $1,000,000
- $2,000,000
- $3,000,000
- $4,000,000
- $5,000,000
Is this limit required by your lease?
- Yes
- No
Restaurant Information
Type of Risk
- Tavern
- Caterer
- Disco
- Hall
- Pizza Parlor
- Take Out Restaurant (No Seating)
- Fast Food Restaurant
- Family Style Restaurant
- Seasonal Restaurant
Clientele
- Local Residents
- Families
- College Students
- Seniors
- Tourists
Average Age of Patrons
- 18-25
- 25-30
- 30-40
- 40 & Over
Building Your Business is Located In
Type of Construction
- Frame
- Jointed Masonry
- Non-combustible
- Fire Resistive
Number of Stories
Other Occupants (Please Describe)
Year Built
Area You Occupy (sq ft)
Area of Entire Building (sq ft)
Sprinkler System
- Yes
- No
Number of Fire Extinguishers
Roof - Year of Most Recent Upgrade (May Need to Consult Landlord)
Electric - Year of Most Recent Upgrade (May Need to Consult Landlord)
Plumbing - Year of Most Recent Upgrade (May Need to Consult Landlord)
Other Upgrades
Upgrade Year of Most Recent Upgrade (May Need to Consult Landlord)

Please press the + symbol to add another upgrade.
Parking
- Valet
- Lot
- Valet & Lot
- Street
Automatic Fire Suppression System (Ansul)?
- Yes
- No
Private Rooms Available?
- Yes
- No
Central Station Fire Alarm?
- Yes
- No
Central Station Burglar Alarm?
- Yes
- No
General Information
Years of Experience in Hospitality Industry
Years Under Current Management
Seasons Open
- Year Round
- Winter
- Spring
- Summer
- Fall
Hours of Operation - Monday (Please Indicate If Closed This Day)
Hours of Operation - Tuesday (Please Indicate If Closed This Day)
Hours of Operation - Wednesday (Please Indicate If Closed This Day)
Hours of Operation - Thursday (Please Indicate If Closed This Day)
Hours of Operation - Friday (Please Indicate If Closed This Day)
Hours of Operation - Saturday (Please Indicate If Closed This Day)
Hours of Operation - Sunday (Please Indicate If Closed This Day)
Do you have table service and seating?
- No Seating
- Seating, No Table Service
- Seating, Including Table Service
Eat In (%)
Take Out (%)
Is there any live entertainment?
- Yes
- No
If Yes, please describe.
Is there dancing?
- Yes
- No
If Yes, describe how often and provide square footage of dance floor.
Do you have any amusement devices?
- Yes
- No
If Yes, please describe.
Do you have a bar, other than a service bar?
- Yes
- No
Do you do TIPS training, or any other training?
- Yes
- No
If Yes, please explain:
Length of Bar (ft)
Number of Seats at Bar
Is there a cover charge?
- Yes
- No
Is there a "happy hour"?
- Yes
- No
Number of Bouncers
Sports on Premises (Darts, Pool Tables, etc.)?
- Yes
- No
Do you sponsor any sports, games, or teams?
- Yes
- No
If Yes, please describe.
Are facilities available for catering, private parties, banquets, weddings, etc.?
- Yes
- No
If Yes, please describe.
Do you have a dock?
- Yes
- No
Are docking facilities available for customer use?
- Yes
- No
Do you use a janitorial service for cleaning floor area and restrooms?
- Yes
- No
If Yes, please provide name of janitorial service.
Kitchen Information
How often are hoods and ducts cleaned?
- Monthly
- Weekly
- Daily
How often are filters cleaned?
- Monthly
- Weekly
- Daily
Who does routine cleaning on hoods, ducts and filters?
- Employees
- Professional Cleaning Service
How often is your automatic fire suppression system serviced?
- Quarterly
- Semi-annually
Date Automatic Fire Suppression System Last Serviced
MM slash DD slash YYYY
Do you have a contract for this service?
- Yes
- No
If Yes, please provide name of contractor.
Is your deep fat fryer at least 18" from an open flame/combustible materials or protected by a metal baffle?
- Yes
- No
Is your deep fat fryer protected by your automatic fire suppression system?
- Yes
- No
Number of Fire Extinguishers
Do you cook in ovens only (no frying or grilling)?
- Yes
- No
Do you cook in microwave ovens only?
- Yes
- No
Exposure Information
Annual Gross Sales for Food ($)
Annual Gross Sales for Liquor ($)
Annual Gross Sales for Catering ($)
Off Premise Catering (%)
Number of Full Time Employees
Number of Part Time Employees
Parking Lot Area (sq ft)
Is Parking Lot Shared with Other Businesses?
- Yes
- No
Inspection Contact
Name
Phone
Must inspector call prior to inspection?
- Yes
- No
If No, when is the best time for our inspector to visit the location?
Mortgage Holder
Name
Address
Street Address Address Line 2 City State ZIP Code
Loss Information
Has your insurance been canceled or non-renewed in the past three years?
- Yes
- No
If Yes, please explain.
Have you had any of the following losses in the past 4 years?
- Property
- Liability
- Liquor
- No Losses
If so, please explain.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Applicant's Signature*
Date*
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

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Contact

Intermarket Insurance Agency

205 East Main St
Suite 3-4
Huntington, New York 11743

Phone: (631) 421-2424

Fax: (631) 421-2004

Mon-Thu: 9:00am-5:00pm
Fri: 8:30am-4:30pm
Sat-Sun: Closed

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