Name
Phone







6650 Reseda Blvd
Suite #108
Reseda, CA 91335

contact@gisinsure.com
RESTAURANT INSURANCE
First Name:
Last Name:
Business Name:
Mailing Address:
Mailing City:
Mailing State:
Mailing Zip Code:
Phone Number:
Fax Number:
E-Mail Address:
Who Referred You To Our Site?

PROPERTY INFORMATION
 

Property Address:

 

Property City:
Property State:
Property Zip Code:
Property County:
Total Square Footage of the Building Your Business Is In:
Square Footage Of Your Business Only:
Square Footage Of The Customer Area:
How Many Stories:
Construction Type:  
Roof Type:  
Roof Updated: yes no  
If Yes, Year Roof was Updated:
Protection Distance:
Is The Business In A Brush Area? yes no  
Is There Storage More Than 1500 Sq Ft? yes no  
Are There Smoke Detectors At This Location? yes no
Smoke Alarm: yes no
Theft Alarm:
Fire Alarm:
Fire Extinguisher: yes no
Deadbolts On All Doors? yes no
Circuit Breakers: yes no
Electrical Updated:
Heating - Air Conditioning, Thermostatically Controlled?: yes no 
Heating - Air Conditioning, Central? yes no
Plumbing Updated: yes no
If Yes, Year Plumbing was Updated:
Interior Automatic Fire Sprinklers: 
Is The Parking Lot Under Your Protection?

yes no

UNDERWRITING INFORMATION
 

Please Describe the Nature of Your Business and Any Unusual Exposures:

 

Number of Owners:
Number of Employees:
Payroll of Owners:
Payroll of Employees:
Total Annual Gross Receipts:
Total Annual HARD LIQUOR Receipts:
Total Annual BEER & WINE Receipts:
Total Annual FOOD Gross Receipts:
Business License Number:
License Type:
Years of Experience:
How Many Years Have You Operated This Business:
Is This Business Open 24 Hours A Day? yes no
Is there Filing Of Propane Tanks? 

yes no  

ENTERTAINMENT INFORMATION
 

Is There Entertainment?

 

yes no

If Yes, Describe:
Is There LIVE Music? yes no
If Yes, Indicate Size of the Dance Floor and Nights Per Week:
Any Coin Operated Amusement Devices? yes no
If Yes, Describe:
Any Pool Tables? yes no
If Yes, How Many And Are They Coin Operated:
Any Bouncers, Doormen, ID Checkers, Armed Guard, Security Guards? yes no
If Yes, How Many Of Each, List Their Job Duties & Are They Your Employees:
Any Contests or Exhibitions? yes no
If Yes, Describe Events:
Any Audience Participation Events? yes no
If Yes, Describe Events:
Do You Sponsor Any Sporting Events? yes no
If Yes, Describe Events:
Did We Miss Any Other Type Of Entertainment, If Yes, Describe:

COOKING INFORMATION
 

Describe The Cooking Devices At Your Business:

 

Tableside Cooking? yes no
Automatic Suppression System? yes no
If Yes, Do They Protect All Hoods, Ducts & Griddles? yes no
Any Deep Frying (Food)? yes no
If Yes, Is There A High Limit Shutoff? yes no
Do You Have An Outside Cleaning Service For The Hoods & Duct System? yes no
How Often Are Hood & Duct Cleaned:
Is There Any Manufacturing, Mixing, Re-Labeling or Repackaging of Products? yes no
Any Delivery Service? yes no
Any Catering Service?

yes no

MISC INFORMATION
 

Losses-Claims in the last 5 years: 

 

 

If yes, date, amount paid and description of each loss-claim
Current Insurance Company:
Current Renewal Date:
Has Insurance Ever Been Cancelled? yes no
If Yes, Describe:
Have You Ever Had Regulatory Violations or Citations? yes no
If Yes, Describe:
Are Employees Trained On How To Handle Minors or Intoxicated Customers? yes no
If Yes, Describe:

COVERAGE INFORMATION
 

Building Coverage:

 

Other Structures Coverage:
Business Contents Coverage:
Loss of Use Coverage:
Liability Limits Requested:
Policy Deductible:
Questions or Comments
to help the Agent: