Restaurant Information Reference

Restaurant Information Reference Rev. 05-15

1

In addition to the information contained on the insurance application, the following information is required when completing the

policy screens for Business (services) operations in TravelersExpress®

for Master PacSM

and Workers’ Compensation.

The information requested in this document is specifically designed to assist you with gathering information so that you may obtain a

Master Pac and/or Workers’ Compensation quote. The information gathered with this document is not intended to supplement or

replace the insurance application. The data captured should be entered into the TravelersExpress®

system to start the quoting

process. While completion of this document is not required, if you elect to use it, a copy should be kept in your file for the account.

Insured Information

Federal Employers Identification Number (FEIN)

Legal Entity: Association Corporation Individual Ltd. Liability Corp. (LLC) Ltd. Liability Partnership (LLP)

Partnership Ltd. Partnership (LP) Joint Venture Trust or Estate Other:

Year business established or acquired by the current owner:

o If less than 3 years, Does the current ownership have 3 years management experience in a related field: Yes No

o Is this a franchised operation: Yes No

Enter the number of owned autos used in the business (not including trailers), 0 if none, or Unknown if not known:

Any owned or leased aircraft used in business: Yes No

General Operations

Hours of operation: No later than 10pm No later than Midnight No later than 2am Past 2am 24 Hours

Operations are open less than eight months per year: Yes No

Total annual sales: $

o Sales $ from: Food: $ Alcoholic Beverages: $ Catering: $ Street Vending: $

Banquet/Reception Services: $

Percentage of sales: Alcoholic Beverages: % Catering: % Street Vending: % Banquet Services: %

Do employees provide deliveries, excluding catering services, as a regular and routine service to customers: Yes No

o Method of delivery: Automobile Motorcycle Scooter/Moped Bicycle On foot

o Is delivery promised within a pre-established timeframe: Yes No

Operations are subcontracted or subcontractors hired for service, maintenance or repair: Yes No

o If yes, Subcontractors required to provide proof of General Liability limits at least equal to the applicant’s: Yes No

o Independent contractors and subcontractors required to provide proof of WC insurance: Yes No

Applicant has no operations in the list of ineligible operations below: Yes No

o Armed security guards

o Bars Night clubs, Pubs or restaurants with liquor sales

in excess of 50% of total annual revenues

o Businesses with any of the following exposures:

o Adult entertainment

o Dance floors

o Happy hours

o Open 24 hours

o Operations on three or more levels)

o Concert venues

o Country clubs or service clubs

o Dinner theaters

o Home-based businesses

o Hookah Bars, Hookah Lounges, or Hookah Cafes

(establishments where customers smoke flavored tobacco

through a water pipe). Also known as Shisha bars

o Marijuana processing, handling or distribution

o Meals on Wheels

o Operations in frame and/or joisted masonry construction

located in protection class 8, 9 or 10

o Street vending in excess of 25% of total revenues

o Seasonal Operations (Open less than 8 months per year)

Master Pac Jump to Workers’ Compensation

Premises Operations

Allows patrons to bring their own alcoholic beverages (BYOB): Yes No

Applicant offers tableside cooking: Yes No

Valet parking is provided: Yes No If yes, valet parking is provided by: Applicant Third Party Vendor

Restaurant Information Reference

Restaurant Information Reference Rev. 05-15

2

Premises Protection

Property Information Notes: All hoods, ducts, grease filters, deep fryers and surface cooking equipment are protected by a UL

listed automatic fire extinguishing system serviced and inspected every 6 months: Yes No

Automatic high temperature shut offs are on all deep fat fryers: Yes No

Emergency lighting is installed and operational: Yes No

Exits are properly lit and equipped with panic hardware: Yes No

Percentage of building sprinklered: 100% 80% to 99% <80% None

o If “100%” or “80 to 90%”, indicate sprinkler system type: Life Safety only Automatic Fire Protection/Extinguishing

o If Automatic Fire Protection/Extinguishing system is selected, confirm the following:

– This building has a fully functioning automatic fire protection or extinguishing sprinkler system covering 80-90%, or 100% of

the building area : Yes No

– I acknowledge that the Protective Safeguards Endorsement will be added to this policy and the insured's rights to payment for

a fire loss may be affected by the terms of this endorsement and I have advised / notified the insured of the potential

coverage limitations: Yes No

Sprinkler system installed for present occupancy: Yes No

Contractor responsible for sprinkler system maintenance and inspection (indicate frequency):

Yes – Monthly Yes – Quarterly Yes – Semi-Annually Yes – Annually Not Maintained/Inspected

Property rating note: If the applicant is a tenant and not the building owner, the value of the applicant’s Restaurant Equipment can

be entered separately from the Business Personal Property using the Restaurant Equipment Limit field for Master Pac.

Additional Information Required by Classification

Banquet and Reception Facilities

Responsibilities for alcohol service, insurance, etc. specifically spelled out in the contract for services: Yes No

Percentage of total annual sales from off-premises catering: %

Fast Food

Formal Wait-staff: Yes No

Playground Exposures: Yes No

o Rules or restrictions are posted: Yes No

o Children are allowed to play unattended: Yes No

o Surface area is a soft surface such as rubber, grass, mulch or sand: Yes No

Catering

Responsibilities for alcohol service, insurance, etc. specifically spelled out in the contract for services: Yes No

Please complete the % of sales for each service to fully describe the catering operation:

o Customer's residential home (parties, weddings, etc): %

o Office events (luncheons, special office events, etc: %

o Special events > 100 people (golf outings, charity dinners, etc.): %

o Banquet and Facility events: %

o Other (describe): and %

o Provides tents or other items (displays, dance

floors, tables, chairs, etc.) at catered events?

Yes No

o Employees set up tents at catered events?:

Yes No

Workers’ Compensation

General Operations

Enter the maximum number of employees per shift at any one location:

Coverage requested for all states (except monopolistic fund states) and locations with known business operations? Yes No

o Describe Exceptions:

o Does the applicant have coverage for states and locations not included in this request? Yes No

o Enter Carrier Name:

Restaurant Information Reference

Restaurant Information Reference Rev. 05-15

3

Do employees travel outside the U.S.: Yes No

Will employees travel to countries, nations or regions on the following list? Yes No

o Afghanistan

o Algeria – Kabyle region and

overland travel anywhere in

Algeria

o Angola

o Bangladesh

o Benin

o Burkina Faso

o Burundi

o Burma (Myanmar)

o Cameroon

o Cape Verde

o Central African Republic

o Chad

o Columbia – small towns &

rural areas

o Comoros

o Congo

o Congo, Democratic

Republic

o Cote d’Ivoire

o Cuba

o Djibouti

o El Salvador

o Equatorial Guinea

o Eritrea

o Ethiopia

o Gabon

o Georgia

o Ghana

o Guinea

o Guinea – Bissau

o Haiti

o Honduras

o Indonesia

o Iran

o Iraq

o Israel – West Bank & Gaza

o Jamaica

o Kenya

o Kosovo

o Kyrgyzstan

o Lebanon

o Liberia

o Libya

o Madagascar

o Malawi

o Mali

o Mauritania

o Mauritius

o Mayotte

o Mexico

o Mozambique

o Niger

o Nigeria

o North Korea

o Pakistan

o Papua new Guinea

o Philippines – Island of

Mindanao & the Sulu

Archipelago

o Reunion

o Rwanda

o Saint Helena

o Sao Tome and Principe

o Saudi Arabia

o Senegal

o Seychelles

o Sierra Leone

o Somalia

o Sri Lanka – Northern or

Eastern provinces

o Sudan / South Sudan

o Syria

o Tanzania

o The Gambia

o Timor

o Togo

o Tunisia

o Uzbekistan – Surkhandarya

Province

o Uganda

o Venezuela

o Yemen

o Zambia

o Zimbabwe

o Rural or Underdeveloped

areas of Tropical

Nations/Regions not listed

above

Will employees travel to countries, nations or regions under a U.S. State Department Travel Warning? Yes No

o See U.S. Department of State Travel Warnings

Enter the estimated number of trips during the next policy year:

Enter the countries, nations or regions where employee(s) travel:

Will any foreign trip be longer than 90 consecutive days (12 weeks): Yes No

travelers.com The Travelers Indemnity Company and its property casualty affiliates. One Tower Square, Hartford, CT 06183 This document does not amend, or otherwise affect, the provisions of coverage of any resulting insurance policy issued by Travelers. It is not a representation that coverage does or does not exist for any particular claim or loss under any such policy. Coverage depends on the applicable provisions of the actual policy issued, the facts and circumstances involved in the claim or loss and any applicable law.

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