Bar/Restaurant Product Application – All States

1 888-523-5545. Bar/Restaurant Product Application All States You can obtain a quote by providing the information in Section I - Instant Quote below, subject to the remainder provided prior to binding. I. INSTANT QUOTE INFORMATION. Instant Quote is only available for accounts with no losses in the past three years. If there is loss history, please complete the entire Application . Applicant's name:_____. Location address:_____ q Same as mailing address. City:_____ State:_ _____ Zip:_____. Web address:_____. Description of operations: Do you own the building? q Yes q No (If No, skip Building Owner Questions under both the Property & Liability Sections below) How many years has the applicant been at the current location?

2 _____. Property Section Construction: q Frame q Joisted masonry q Non-combustible q Masonry non-combustible q Modified fire-resistive q Fire-resistive q Other_ _____. Protection class:_____. Requested cause of loss: q Basic q Special Requested valuation: q Replacement cost q Actual cash value Deductible: q $1,000 q $2,500 q $5,000. Coinsurance: q 80% q 90% q 100%. Business personal property limit $_ _____. Business income and extra expense limit $_ _____. Is there commercial cooking on the premises? q Yes q No What type of extinguishing system is functioning and operational?

3 Q Wet q Dry Is there a deep fat fryer on the premises? q Yes q No Building Owner Building limit $_____. What year was the building constructed?_____. What is the square footage of the entire structure?_____sq. ft. Is the building fully protected by an operational sprinkler system covering 100% of the premises? q Yes q No General Liability Section Food Sales Alcohol Sales Other Receipts Total Annual Receipts $ $ $ $. Limit: q $100,000/$200,000 q $300,000/$600,000 q $500,000/$1,000,000 q $1,000,000/$2,000,000. Years of experience the applicant has in managing this type of operation_____ How many nights of major entertainment per week?

4 _ _____. Is the applicant a Gentlemen's Club or is adult/exotic dancing provided? q Yes q No Is there a dance floor? q Yes q No Are there tables? q Yes q No If Yes, is there table service? q Yes q No Does the applicant hire or utilize bouncers? q Yes q No What is the latest hour of operation?_____. Is alcohol served after midnight? q Yes q No In the past three years, have there been any previous claims involving assault and/or battery? q Yes q No Building Owner Is any portion of the building leased to commercial tenants? q Yes q No If Yes, applicable sq. Does the applicant lease any apartments at this location?

5 Q Yes q No If Yes, number of units _____ applicable sq. Additional Interests (AI = Additional Insured, LP = Loss Payee, M = Mortgagee). Name Relationship/Interest Address City, State, Zip AI LP M. q q q q q q q q q If you desire a Liquor Liability Quote, please complete Section IV Eligibility Criteria, Liquor Liability section of this Application . BRPA 7/11 page 1 of 5. LOSS INFORMATION FOR THE PAST THREE YEARS. II. Property Coverages q None, or provide detail below. Year Status Incurred Description Closed _ _____ Open/Closed $_ _____ _____. Closed _ _____ Open/Closed $_ _____ _____.

6 Closed _ _____ Open/Closed $_ _____ _____ General Liability Coverages q None, or provide detail below. Year Status Incurred Description Closed _ _____ Open/Closed $_ _____ _____. Closed _ _____ Open/Closed $_ _____ _____. Closed _ _____ Open/Closed $_ _____ _____ III. ADDITIONAL PROPERTY INFORMATION. If you own the building and it is more than 10 years old, please complete the following: Age of roof_____yrs. Plumbing updated (yr)_ _____ Electrical updated (yr)_ _____ Heating updated (yr)_____. Roof type: q Flat q Wood shake q Shingle q Metal q Tile q Slate q Other_____.

7 Plumbing type:q PVC q Copper q Lead q Galvanized q Other_____. What type of burglar alarm is on the premises? q Central station q Local gong q None IV. ELIGIBILITY CRITERIA 1. No bankruptcies, tax or credit liens against the applicant in the last five years q True q False 2. No tax liens or back taxes owed on the property q True q False 3. Coverage has not been cancelled or non-renewed in the last three years (not applicable in Missouri) q True q False If False, advise reason_____ Property 1. For any building built prior to 1978, 100% of the electric wiring is on functioning and operating circuit breakers q N/A q True q False 2.

8 For any building built prior to 1978, there is no aluminum wiring or knob and tube wiring q N/A q True q False 3. All cooking equipment has an in-force cleaning contract q True q False 4. Business does not operate on a seasonal basis q True q False 5. Functioning and operational fire extinguishers available q True q False 6. Functioning and operational smoke and/or heat detectors in all units and/or occupancies q True q False General Liability 1. Applicant has not, is not and will not act as a franchisor (grantor of a franchise) q True q False 2. All public areas are equipped with functioning and operational smoke/heat detectors q True q False 3.

9 All alcohol served within the legally allowable time frames q True q False 4. Applicant is the only occupancy in the building or all deep fat frying appliances have automatic extinguishing systems and are all NFPA 96 compliant q True q False 5. Every floor with public access has at least two means of egress (exits) q True q False 6. No exposure to pyrotechnic displays, foam machines, moon bounces, trampolines, rock walls or swimming pools q True q False 7. No exposure to mechanical bull or mechanical riding devices q True q False 8. Not situated on a vessel q True q False 9.

10 Patrons under 21 years of age are not permitted in the bar area after 11 and applicant does not have teen, under 21 or similar functions q True q False 10. No inhalation of oxygen gas from tanks or hookah smoking on premises q True q False Liquor Liability 1. Is the applicant a nonprofit private, fraternal or social club? q Yes* q No *If Yes, please answer the following: a. Are same-day memberships available? q Yes q No b. Are members permitted to bring more than three guests per day (excluding banquet activities and immediate family members)? q Yes q No c. Is self service of alcohol permitted by members?