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COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

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  • 82 check-boxes
  • 29 other fields

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C‐APP0034‐0815 Page1of4
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION - RESTAURANT - SUPPLEMENTAL APPLICATION
ACORD Application also required - Check all applicable checkboxes below
General Agent:
Date:
Insured:
Insured Mailing Address:
Insured’s Web Address:
Insured Contact Name:
Phone Number:
PROHIBITED (check all that apply to your operations)
Armed security unless an off duty certified policy officer
Bar/Tavern (including Sports Bars), IF they are a stand alone operation
Bouncers if more than one
BBQ / Smoker inside premises
BBQ pits or smokers within premises or within 100 feet of building
BYOB (Bring Your Own Liquor)
Dance clubs, even if food is served
Gentlemen’s club
Hookah bars
Hours open are later than 2 AM
Liquor receipts exceed 30% of combined annual total receipts for food and liquor
Mechanical Bull
Opten Fire Pits
Oxygen bars
Playrooms or playgrounds
Playrooms or playgrounds for children
Teen clubs with or without food, with or without dancing
Valet Parking if done by employees
YEARS IN BUSINESS / EXPERIENCE
_____ Years in business as the ‘Named Insured’ indicated on this application
_____ Years’ experience in the operations indicated on this application - Attach resumes if available
_____ Owners are actively involved in the day-to-day operations
_____ Years in business at this location(s)
Has applicant had an insurance policy cancelled or non-renewed in past 3 years? If yes, explain.
(Missouri Applicants - Do not answer this question)
Applicant in receivership
Bankruptcy (Chapter 7, 11 or 13) has been filed in past 10 years
C‐APP0034‐0815 Page2of4
RESTAURANT - SUPPLEMENTAL APPLICATION
LOSS HISTORY
Three years of loss history information provided on ACORD application or attached to this application
Assault and Battery incident(s) have occurred in the past 3 years
OPERATIONS / EXPOSURES / CONTROLS
Building:
Apartment units are on the premises & premises owned by the insured. Number of apartments: _______
Beach, dock, piling, pier or wharf exposures exist
Building(s) are regularly maintained and are currently in good repair, not in a deteriorating condition
Emergency lighting in place
Exit signs in place and illuminated at night
Fire extinguishers in place as required by local codes and all have current service tags
Panic bars on all exit doors, all exit doors unlocked during operating hours, exit areas not blocked
Parking lots, ramps, sidewalks, steps are properly marked, maintained and in good repair
Premises are currently listed ‘for sale’
Catering off-premises
Cooking:
Automatic fuel shut-off in place for cooking equipment
BBQ pits or smokers must be monitored at all times
Extinguishing system (automatic) protects all grease cooking equipment (or grease vapor producing
equipment), ducts and grease filters
Cleaning of ducts, exhaust filters and hoods is done by professional, insured, third party service
at least semi-annually
Manual release for the automatic extinguishing system is located outside of kitchen
Fryers have auto-temperature-shut-offs, noncombustible barriers & are at least 18” from combustibles
Open flame cooking with real wood logs, not wood chips (wood chips acceptable)
Tableside cooking
Dance floor:
If yes, what Is the square footage of the dance floor: _______ square feet.
DJ
Live bands - describe types of music:
Other types of entertainment (describe):
Liquor:
Liquor is served (If Liquor Liability is needed please complete the Liquor Liability Supplemental)
After hours exposures exist
Happy Hour drink specials
ID’s checked for anyone looking under 21
ID’s required for anyone looking under 40
Off – Premises:
Catering off-premises
Delivery of food to customers – phone or text ordering
Parking:
Parking areas are under the applicant’s control
Valet parking provided by insured’s employees
Subcontracted to insured, third party who provides evidence of Garage Keepers Legal Liability (GKLL) and
Auto Liability
C‐APP0034‐0815 Page3of4
RESTAURANT - SUPPLEMENTAL APPLICATION
OPERATIONS / EXPOSURES / CONTROLS (continued)
Rental:
Rental of facilities to third parties. Number of times per year (estimated): ______
Seafood:
Seafood – Raw Percentage of food sales that are raw: ______ %
Security includes:
Bouncers – Employees Bouncers – Subcontracted
Central station burglar alarms
No known history of fights or rowdiness
Security – third party – off duty peace officers
Security – third party, insured and providing applicant with additional insured status on their policy
TIPS / TOPS LIQUOR SERVICE TRAINING
Training (TIPS, TOPS or similar) is provided to ALL employees handling liquor
Trash:
Trash disposal includes proper handling of smoking materials (if smoking is allowed). All trash is placed in
metal trash bins that are stored away from the building.
SUBCONTRACTORS
Uninsured Subcontractors are not acceptable.
Risk Transfer – Subcontractors:
Additional Insured – Status granted to you on the subcontractor’s policy
Certificates of Insurance - Always obtained from a subcontractor prior to any work being done for you.
Limits of Liability - Subcontractors are required to carry limits equal or above your own
EMPLOYEES
Total Number of Employees (include leased employees): __________
RECEIPTS
Food Only
$
Liquor Only
$
Other
$
Total of Food, Liquor and Other
$
DISCONTINUED OPERATIONS / DISCONTINUED NAMED INSUREDS:
Discontinued Operations for this application’s Named Insured(s) in the past 10 years. Provide details below:
Operated under a different ‘Named Insured(s)’ in the past 10 years. Indicate the Named Insured(s) and
corresponding operations for the Named Insured(s) below:
C‐APP0034‐0815 Page4of4
RESTAURANT - SUPPLEMENTAL APPLICATION
COVERAGE OPTIONS - LIABILITY (check if you would like an optional quote on any of the following)
Employee Benefit Liability – U058
Employment Practices Liability Insurance – U817 (Not available in AR, LA, MT, NM, NY, VT)
High Limits General Liability
Identity Recovery – i.e. Identity Theft – U651
Medical Expense Limit of $10,000 rather than $5,000
Stop Gap Liability – U066
COVERAGE OPTIONS - PROPERTY (check if you would like an optional quote on any of the following)
Building Ordinance or Law (Increased Cost of Construction) – U750
Equipment Breakdown – U522 & U523
Property Coverage Enhancement:
Bronze – U777C Silver – U777B or Gold – U777A
Signs (Outdoor) – CP1440
Water Back Up and Sump Overflow – U548
GENERAL FRAUD STATEMENT (Not applicable in all states.)
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 any materially false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, may be committing a fraudulent insurance act, and may be subject to
a civil penalty or fine.
The undersigned is an authorized representative of the applicant and certifies that reasonable inquiry has been made to
questions on this application. He/She certifies:
The answers are true, correct and complete to the best of his/her knowledge.
They agree to the Privacy and Fraud provisions found in the ACORD-125 (Commercial Insurance Application)
and understand those provisions also apply to this supplemental application.
SIGN AND DATE
PRODUCER’S SIGNATURE DATE
APPLICANT’S PRINTED NAME DATE
APPLICANT’S SIGNATURE DATE
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COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

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Completed 17 July 2021

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