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Absolute Insurance Services
601 South White Horse Pike
Winslow NJ 08037
Phone 609-567-2222
Email: info@absoluteinsuranceservices.com
Website: www.absoluteinsuranceservice.com
Application Form
Named Insured
*
DBA
Web Address
Location Address
City
County
State
Zip Code
Mailing Address (if different)
Current Carrier
Effective/Renewal Date
Current/Target Premium $
Has Current Policy Been Canceled or Non-Renewed
Yes
No
If Yes, Describe
This Owners/Shareholders Information Must be Entered To Bind Coverage
Owners Name (Principal)
SS #
D/O/B
Home Address
Home Phone #
Business Phone #
Business Information
Applicant is a:
Corporation
Partnership
Individual
Other
Applicant is a:
Restaurant
Diner
Tavern
Night Club
Banquet Hall
Social Club
Night Club
Other (Please Specify)
Applicant is located in:
City
Small town
Rural area
Other
# Years at this Location
# of years in Restaurant/Tavern Business
If less than 3 years at this Location, list previous experience
Federal EIN #
Liquor License #
Legal Bldg. Occupancy
Franchise
Yes
No
Chain
Yes
No
Operations Section
Is Applicant Open Now
Yes
No
If “No”, Explain
Hours of Operation From
To
# of Days per Week
Is Applicant a Seasonal Operation?
Yes
No
If “Yes”, explain
Distance to Ocean or Nearest Body of Water
Financial Information
Is Owner or Corporation now or ever involved in:
Bankruptcies
Yes
No
Foreclosures
Yes
No
Tax Liens:
Yes
No
Business Failures:
Yes
No
Any Litigations:
Yes
No
If Yes, Please Explain
Physical Plant Section
Age of Building
Construction
Protection Class
# of Stories
Age of: Wiring
Plumbing
Heating
Roofing
Other Occupants:
Yes
No
If Yes, Type of Occupancy
Smoke Detectors
Yes
No
If Yes, Type:
Electric
Battery Power
Fire Alarm
Yes
No
If Yes, Type:
Central Station
Local
Burglar Alarm
Yes
No
If Yes, Type:
Central Station
Local
Video Cameras
Yes
No
Sprinkler System
Yes
No
If “Yes”, Age
Type of System:
Wet
Dry
Volunteer Fire Department
Yes
No
Distance To: Hydrant
Fire Dept
Kitchen Fire Protection:
Yes
No
U.L. Approved Automatic Extinguishing System under Semiannual Contract
Yes
No
Above System Covering All Cooking Surfaces
Yes
No
System Name
Wet
Dry
Automatic Gas or Electric Shut Offs for Cooking
Yes
No
Hood and Filters Cleaned Weekly by Staff
Yes
No
Hoods and Ducts Over All Cooking Equipment
Yes
No
Hoods and Ducts Maintenance Contract Schedule
# Month
Fire Extinguishers
Tag Dates
Is Kitchen Sub-leased
Yes
No
If Yes, Explain
Table Cooking or Tableside Cooking
Yes
No
If Yes, Explain
Entertainment Section
Entertainment
Yes
No
If “Yes”, ENTIRE Section MUST be Completed
Nights w/Ent:
Fri
Sat
Sun
Mon
Tue
Wed
Thu
Clientele Avg. Age
Type of Entertainment
Rock Group
DJ
Band (Any Kind)
Go-Go
Karaoke
Other (Please Describe)
Cover Charge
Yes
No
IF Yes, Describe When & Why
Dance Floor or Stage Exist
Yes
No
If Yes, Square Ft
Is Dancing Permitted
Yes
No
Amusement Devices (Pool Tables, Video Games, etc.)
Yes
No
If “Yes”, # and description
Liquor Legal Liability Section
Does Applicant Serve Alcohol
Yes
No
If “Yes”, Entire Section MUST be Completed
Does Applicant Have Liquor License
Yes
No
If “Yes”, Type and #
# of Bar Seats
Max # of staff per shift:
Bartenders
Wait Staff
Avg. Employment Exp.
yrs.
Alcohol Server Training
Yes
No
If “Yes”, Explain Type and When Trained
Does Applicant Have Written Policy on Serving Alcohol to Customers
Yes
No
Is Management Notified Prior to Shutting Off Patrons
Yes
No
Is Documentation Kept on Each Incident
Yes
No
# of Bars on Premises
Is There a Steady Bar Clientele
Yes
No
Is There a Happy Hour
Yes
No
Reduced Price Drinks
Yes
No
Is a Last Call Given
Yes
No
If “Yes”, What Time
Have There Been Any ABC Violations
Yes
No
If “Yes”, List ALL Violations
Property Section
Does Applicant Own Building
Yes
No
Is Applicant Required by Lease to Insure Bldg.
Yes
No
Building Limit $
Co-Ins %
ACV
R/C
Deductible $
($1,000 Min)
Imp. & Betterments Limit $
Co-Ins %
ACV
R/C
Deductible $
($1,000 Min)
Contents Limit $
Co-Ins %
ACV
R/C
Deductible $
($1,000 Min)
Business Income Limit $
Contribution or Co-Ins %
Waiting Period: 72 Hours
With Extra Expense
Yes
No
Loss of Rents Limit $
Co-Ins %
No Waiting Period
Cause of Loss:
Basic
Special
Property Enhancement Endorsement Requested
Yes
No
Other Property Coverage Requested
Liability Section
General Liability Limit $
Aggregate $
Liquor Liability Limit $
Aggregate $
Is Lessors Risk Required
Yes
No
If Yes, Supply Square Footage
Business Occupant
Receipts: Food $
Liquor $
Admission $
Other $
Total $
Are There Apartments
Yes
No
If Yes, Number of Units
Owner Occupied
Yes
No
Are There Lodging Operations Other Than Apartments
Yes
No
If Yes, Describe
Square Footage: Total Building
If Restaurant, Table Seating Capacity
Off Premise Parking
Yes
No
If “Yes”, list address, square footage(or # spaces)
On or Off Premise Catering / Banquet
Yes
No
If “Yes”, % of total Receipts
%
Describe Catering Operation
Describe Any Other On or Off Premise Exposures NOT Listed Above
Security
Are any Bouncers, Door Persons, Crowd Control or Security Used
Yes
No
If Yes, Describe Type and Purpose:
Are Any Non-Employee Security Services Hired or Contracted
Yes
No
If Yes, Describe Type and Purpose:
In the Last 12 Months Have Any Emergency Services Been Called; i.e. Police, Ambulance, Fire
Yes
No
If “Yes”, Explain:
Non-Owned Automobile (Hired Auto Not Available)
Is Non-Owned Automobile Requested?
Yes
No
If Yes, Complete Entire Section
Number of Employees
Does Applicant have a Business Auto Policy?
Yes
No
Any Delivery Use?
Yes
No
List the Business Purposes the Non-Owned Auto will be Utilized for:
Claims Section
List ALL Claims for the Past 5 Years. If Yes, Describe Loss.
Property Claims
Yes
No
General Liability Claims
Yes
No
Liquor Liability Claims
Yes
No
Additional Interests
Mortgagees, Additional Insureds and Loss Payees are defined as Additional Interests
There are Additional Interests listed of this Application and are by this acknowledgement included in the information
that is warranted by the signature(s) below.
If the box above is not checked it is understood that there are no Additional Interests to this application
Select type
Additional Insured
Mortgagee
Loss Payee
Name
Address
City, State and ZIP
Interest
Select type
Additional Insured
Mortgagee
Loss Payee
Name
Address
City, State and ZIP
Interest
Select type
Additional Insured
Mortgagee
Loss Payee
Name
Address
City, State and ZIP
Interest
Select type
Additional Insured
Mortgagee
Loss Payee
Name
Address
City, State and ZIP
Interest
Select type
Additional Insured
Mortgagee
Loss Payee
Name
Address
City, State and ZIP
Interest
Additional Owners/Shareholders
Must Be Completed and Signed By All Owners/Shareholders To Bind
Name
Soc. Sec. #
Date of Birth
Name
Soc. Sec. #
Date of Birth
Name
Soc. Sec. #
Date of Birth
Name
Soc. Sec. #
Date of Birth
The signing of this application does not bind the Applicant nor any company to complete the insurance, but it is agreed that the information contained herein, and on any additional pages, if any, shall be the basis of the acceptance of a contract. It is therefore the warranty of the undersigned that the information contained herein is true and correct, and it is hereby understood that the policy will be warranted based on this information. It is further understood that 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 commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties. I hereby authorize Absolute Insurance Services to run any credit reference checks in accordance with the Fair Credit Reporting Act (91-508), should they deem necessary.
Insured’s Signature
Date
Insured’s Signature
Date
Insured’s Signature
Date
(Must Be Signed by All Owners to Bind)
Are you the controlling agent on this account?
Yes
No
Producer
Agent
Phone #
Address
Fax #
Agent Signature
E-mail address
Comments/Notes
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