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• Coverage Start Date *

• Company Name *

• Contact Name *

• Contact Email *

• Phone *

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• Number of Employees *

• Years in Business *

• Losses in past 5 years? *

YES

NO

• Please explain the details of your loss experience

• Building *

RENT

OWN

• How many Residential Units are there above the Building? *

• Amusement Devices *

YES

NO

• Delivery *

YES

NO

• What third party delivery service are they using? *

1. Servers trained in responsible alcohol serving practices (ie TIPS or ServSafe Alcohol) *

YES

NO

2. Alcohol service stopped 1 hour prior to closing *

YES

NO

3. Do they allow BYOB *

YES

NO

• Building or facility used for the purpose of hosting parties, banquets, etc: Private events within the restaurant *

YES

NO

• Maintain walking surfaces with appropriate safety measures in areas prone to slip, trip, and fall: *

YES

NO

• Cooking: Outdoors or in a secondary structure? *

YES

NO

Does restaurant utilize cooking equipment that uses grease such as fryers

YES

NO

• Equipped with a UL 300 compliant automatic extinguishing system? *

YES

NO

• Commercial cooking equipment separation requirements: Select which statement applies *

1

2

3

1. Maintains a 16‐inch space between any open‐flame cooking equipment (such as gas‐fired range) and deep fat fryer:

2. Maintains a vertical noncombustible barrier that extends 8 inches above the top of the deep fat fryer and open‐flame cooking equipment, if a 16‐inch space is not possible

3. Neither 1 or 2

• Kitchen equipped with a manual activator pull station, easily accessible and located along a route of egress? *

YES

NO

• Uses a hood and ventilation system: *

YES

NO

• Professionally installed according to National Fire Protection Association Standard 96: *

YES

NO

• Serviced at least Quarterly by a contractor: *

YES

NO

• Only baffle style (not mesh style) hood filters used: *

YES

NO