Corporation: Name & DBA Contact Person: Email Address: Physical Address: Mailing Address: City, State, Zip: (Must be in New York!) Phone #: Fax #: Effective Date/Renewal Date: # of years in business: Food Sales: Alcohol Sales: Cover Sales: Misc. Sales: Building Information: Sq. Feet of Building: Number of Stories: Basement? Yes No Adjacent Tenants: Yes No Building Construction Type & Age: Roof Construction Type & Age: Updates/years: Wiring: Roofing: Plumbing: Heating: Located within city limits? Yes No Distance to shoreline? Cooking: Yes or No Yes No If yes, ansul system: Covers: all foods? Yes No Deep Fat Fryers? Yes No Open Flames? Yes No Service Contract for Cleaning? Yes No Cleaning company name? Date last cleaned? How often? Auto fire extinguishing system? Yes No Security System: Yes No Name of Monitoring Co: How many fire extinguishers: Sprinklered? Yes No Distance from fire hydrant? Distance from Fire Station? Operations   Hours of Operation: From: To:   M T W Th F Sat Sun Is there entertainment? Yes No What type & how often? How many video games, pool tables, darts, etc? Dancing: Yes No If yes, Sq. feet of dance floor Coverage Liability Amount: Liquor Liab: Assault & Battery: Yes No Non-owned/hired auto: Yes No Building Amount: Contents Amount: Tenant Improvements: Loss of Income: Do you currently have insurance? Yes No With Who? Present Premium: Policy #: Loss Information (Prior 5 years; dates & amounts: Loss Payee Info: Additional Insured Info: General Information Any policy declined or cancelled during the prior three years? Yes No Any bankruptcies, tax or credit liens against the applicant in the past five years? Yes No Is parking lot under insureds control? Yes No If yes, square footage: Is valet parking provided? Yes No If yes, employees or service? Has there been any incidents involving assault & battery in the past three years? Yes No Number of bartenders/servers? Full time Part time Do you have a formal written safety program? Yes No Average age of clientelle? What is the seating capacity? When is Happy Hour? Ladies Night? What type of Certified training for bartenders and servers?