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Colonial General Insurance Agency, Inc. BAR, TAVERN & (Colonial General Insurance Agency, Inc)

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MS108 (10/2000) Page 1 of 2
Colonial General Insurance Agency, Inc.
Fax to: (480) 948-1394 or Toll Free to: (866) 240-8807
BAR, TAVERN & RESTAURANT SUPPLEMENTAL APPLICATION
First Named Insured: Date:
1. Type of business: ¨ Restaurant* ¨ Night Club ¨ Banquet Facility
¨ Bar/Lounge ¨ Cafeteria ¨ Other:
2. Seating Capacity: TOTAL Dining Area Bar/Lounge Area
3. Do you have dancing? ¨ Yes ¨ No
If ‘Yes’:
a. What is the dance floor area?
b. What type of music is played?
4. Are floor shows or other live entertainment provided? ¨ Yes ¨ No
If ‘Yes’, please describe:
5. Do you serve alcoholic beverages? ¨ Yes ¨ No
If ‘Yes’:
a. Percent of total sales for alcohol:
b. Do you have a happy hour? ¨ Yes ¨ No
c. Are there written and enforced policies for intoxicated customers? ¨ Yes ¨ No
6. Do you employ or use security guards or bouncers? ¨ Yes ¨ No
If ‘Yes’:
a. Are they: ¨ Employees ¨ Contracted Labor
If contracted labor, do you require them to carry: ¨ General Liability Coverage
¨ Workers’ Compensation Coverage
b. Do they carry weapons? ¨ Yes ¨ No
c. Have they been trained on alternative uses of force, regulations and laws? ¨ Yes ¨ No
d. Do you require certificates of insurance? ¨ Yes ¨ No
Limits of liability required:
7. Type of clientele: ¨ Blue Collar ¨ Rural/Country ¨ Middle-age ¨ Singles
¨ White Collar ¨ College Students ¨ Families ¨
8. Average Age of clientele: ¨ 18 - 25 ¨ 26 - 35 ¨ Over 35
9. Have you ever had the following:
a. Liquor liability claims? ¨ Yes ¨ No
b. Liquor violations? ¨ Yes ¨ No
c. Suspended or revoked liquor license? ¨ Yes ¨ No
d. Assault or battery incidents? ¨ Yes ¨ No
10. Do you have mechanical or amusement rides? ¨ Yes ¨ No
If ‘Yes’, please describe:
*To be classified as a restaurant, the liquor sales must be less than 35% of total receipts.
Fax to: (801) 290-1160 or Toll Free to: (800) 332-9285
MS108 (10/2000) Page 2 of 2
11. Do you have any recreational facilities? ¨ Yes ¨ No
If ‘Yes’, please describe:
12. Type of cooking devices: ¨ Gas ¨ Electric
13. Do you have a deep fat fryer? ¨ Yes ¨ No
Does it have automatic fuel shut-off? ¨ Yes ¨ No
14. Is there a hood and duct system? ¨ Yes ¨ No
Does it have filters? ¨ Yes ¨ No
15. How often are the hood and duct systems cleaned?
¨ Every 3 Months ¨ Every 6 Months ¨ Other:
16. How often are the filters cleaned? ¨ Weekly ¨ Monthly
17. Is there an automatic extinguishing system? ¨ Yes ¨ No
Does the system cover all cooking surfaces including deep fat fryers? ¨ Yes ¨ No
18. Does the insured have a maintenance contract? ¨ Yes ¨ No
19. Is housekeeping clean and orderly? ¨ Yes ¨ No
20. Are all trash receptacles checked at closing and emptied into covered metal containers? ¨ Yes ¨ No
21. Please indicate the number of fire extinguishers located in:
a. Cooking Area (BC Type)
b. Dining Area (ABC Type)
Date last serviced and recharged:
Applicant’s Signature Date
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Completed 22 August 2020

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