Restaurants- Hutch BusinessBusiness name:Legal entity:First ChoiceSecond ChoiceThird ChoiceNumber of employees:Contact name: First Last Phone:Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Other location(s): Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email: Website / Social Media:Annual sales:Annual payroll:Federal tax ID number:Franchise:YesNoCurrent carrier:Years with current carrier:Policy expiration date: MM slash DD slash YYYY Number of claims:Claim(s) details:Type of restaurant:Seating capacity:Square foot area:Number of employees:Receipts for Alcohol:Receipts for Food:Total:UnderwritingHas the Applicant ever been canceled (incl. nonpay) or refused insurance of any kind by ERIE or any other insurance carrier?YesNoIf yes, please explain:Has the Applicant filed for bankruptcy in the past 5 years?YesNoIf yes, please explain:All RestaurantsIs restaurant(s) open past midnight?YesNoWhat are the hours of operation?Is restaurant(s) seasonal?YesNoIf yes, list dates closed:Is restaurant(s) part of a franchise?YesNoIs food or alcohol delivered by vehicle?YesNoBy foot or bicycle?YesNoIs more than 5% of food served raw fish or meats?YesNo(i.e. sushi, oysters, steak tartare, etc.)Do designated employees receive annual training on safe food handling practices?YesNoAny critical or high food service or health board violations?YesNoScore / Date:Is there a written procedure to document slips and falls, objects in food, food poisoning and other complaints?YesNoAre all floors in good repair and nonslip precautions in place?YesNo(look for tripping hazards)Are slicer safety features in place?YesNoIs cleanliness of the food preparation area good?YesNoAre exit doors easily accessible, unblocked, and lit?YesNoAre the sidewalks, entry areas and parking lot in good condition?YesNoKitchen Fire Protection (Complete this section ONLY if commercial cooking is performed.)Are all cooking surfaces and deep fryers covered by a metal exhaust hood with ductwork?YesNoIs there a written contract for commercial cleaning of the exhaust hood, including ductwork and filters?YesNoIf Yes, what is the schedule?(i.e. monthly, quarterly, semi-annually, annually?)Date of last inspection:Are all commercial cooking surfaces and deep fryers protected by a WET automatic chemical extinguishing system?YesNoIs the automatic extinguishing system(s) serviced under a written maintenance contract at least every 6 months?YesNoDate of last inspection:Is the automatic extinguishing system ever disconnected?YesNoIf yes, why?Are the filters, hood, rear wall and appliances free of grease accumulation?YesNoAre the outside wall, roof and bell housing free of grease accumulation?YesNoDoes restaurant(s) have banquet hall facilities seating more than 50 people?YesNoIf yes, what is the seating capacity?Is any tableside cooking performed?YesNoAre there any open pits/hearths or open flame grills?YesNoIf yes, please describe in detail:Are there Class K fire extinguishers and are they serviced annually?YesNoIs there a fire alarm?YesNoIf yes, Central or Local:CentralLocalEntertainmentCheck all that apply: Volleyball/Sports Pool Table Live Band Dance Floor Stage Play Pyrotechnics DJ Playground Karaoke Dart Board Piano None Types of entertainment and how often? Example: The restaurants supports club sports… “What type of club sport, and how often?”Liquor LiabilityLimits of liability requested:Each Common Cause:Policy Aggregate:Does business have a formal alcohol awareness training program?YesNoIf yes, what is the name of the program?(TIPS, TOPS, etc.)If yes, are all servers/bartenders required to attend the program within 60 days of hiring?YesNoIf yes, do you make written material available to reinforce the skills learned in the training program?YesNoHas the Applicant submitted any claims in the past 5 years regarding liquor liability coverage or had any incidents that might give rise to a claim?YesNoIf yes, provide details:Has Applicant been cited or fined by a government agency for any liquor violations?YesNoIf yes, provide details:Has the Applicant ever had their liquor license suspended or revoked?YesNoHas liquor liability coverage ever been canceled, non-renewed or denied in the past?YesNoIf yes, provide details:Is there a separate bar or lounge area?YesNoDoes business have any bouncers, security guards, doormen, or ID checkers?YesNoDoes business supply the bartender/ servers for catered events?YesNoAre receipts from catering operations more than 25% of your total receipts?YesNoIf yes, provide details:Check all that apply: Happy hour Drink specials Flaming drinks Ladies’ /Men’s nights Cover charge None PropertyBlanketYesNoContents:Deductible:Additional Property (signs, lights, clocks, fences, playgrounds, etc.)Construction type:Protection class:Year built:Building square footage:Applicant square footage:Number of stories:List other tenants: Add RemoveBuilding designed for current use?YesNoSewer / Drain:Employee dishonesty:Computer coverage:Include enhancement endorsementYesNoPremises ExposuresSmoke Alarms:HardwiredSealed lithium9-V batteryFire Alarm:CentralLocalNoneMoney on premises:How often are bank deposits?Money in safe:Year of roof:Roof type:AsphaltShinglesMetalSlate/TileFlatRoof condition:ExcellentGoodFairPoorRoof concerns:NoneSaggingMissing shinglesWorn shinglesBurglar Alarm:CentralLocalNoneOutside lighting:AdequateInadequatePeeling / Flaking paint?YesNoIf yes, where?Any Deterioration / Dry Rot?YesNoIf yes, where?Foundation condition:GoodCrackingDisrepairWalking surfaces:GoodUnlevelHolesHeating type:ElectricGasOilHeating condition:GoodPoorAge:Electrical condition:GoodPoorAge:Overall Housekeeping?ExcellentGoodFairPoorGeneral Liability LimitSelect one:300 / 600500 / 10001000 / 2000Umbrella?YesNoRating basis:Sales / Receipts:Payroll:Data Breach liability:Employee benefit liability:Employment practices liability:Deductible:Number of Employees (full-time):Number of Employees (part-time):Third-party coverage?YesNoWorkers’ CompensationExpert modification factor:Expert modification date: MM slash DD slash YYYY Sole proprietor / Partners coverage?YesNoCorporate officer coverage?YesNoListClass code #:Payroll = Add RemoveAverage length of employment:Safety: Safety meetings Lifting training Forklift training PPE training (check all that apply)Eye washing stations?YesNoAutosAuto used in business?YesNoAutos titled to?Hired / Non-owned?YesNoDo your corporate officers maintain a personal auto policy?YesNoIf no, consider adding the corporate officers named coverage endorsement.Included at direct primaryLimit is actual lossLiabilityMed PayUm / UimCompCollListYearMakeModelVIN Add RemoveDocumentsCheck each box when complete: Exterior photos of front and back Interior photos (bar area, seating area, kitchen cooking line, hood cleaning sticker, automatic extinguishing system service tag, entertainment, if any) Loss runs Copy of cleaning contract