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California Fast Food Safety Association

 Restaurant Casualty Insurance Programs

	General Information: Insurance Type [Select Insurance Type] General Liability Property Coverage GL & Property Liquor Liability Only Other Business Name Contact Name Email Address Verify Email Address Phone Number Fax Number Business Address City, State, ZIP FEIN or SSN Business Entity [Select Business Entity] Individual Partnership Corporation Joint Venture Subchapter S-Corp. Not For Profit Org Limited Liability Corp Years in Business [Select Years in Business] New Business 1 2 3 4 5 6 7 8 9 10 or More Years Experience [Select Years Experience] None 1 2 3 4 5 6 7 8 9 10 or More Description of Business Operations Business Classification:   Type of Restaurant [Select Type of Restaurant] Restaurant Bar Tavern Nightclub Fast Food Banquet Hall Bed & Breakfast Inn Diner Family Style Other Is Seating Available ? [Select Seating Availability] With Seating Without Seating Concessionaires Concessionaires - Not for profit Is There Table Service ? [Select Table Service] With Table Service Without Table Service Is There a Dance Floor ? [Select Dance Floor] With Dance Floor Without Dance Floor Live Entertainment ? [Select Live Entertainment] With Live Entertainment Without Live Entertainment Is There Catering ? [Select Catering Service] With Catering Service Without Catering Service Are There Deliveries ? [Select Delivery Service] With Delivery Service Without Delivery Service Alcohol Receipts [Select Alcohol Receipts] None Less than 30% of Receipts 30% to 50% of Receipts 51% to 74% of Receipts 75% or More of Receipts Desire Liquor Liability ? [Select Liquor Liability Coverage] With Liquor Liability Without Liquor Liability Is There Happy Hour ? [Select Happy Hour] With Happy Hour Without Happy Hour Full-Time Employees [Select Number of Employees] Owner(s) Only 1 2 3 4 5 6 7 8 9 10 or More Part-Time Employees [Select Number of Employees] None 1 2 3 4 5 6 7 8 9 10 or More Bouncers or Doormen ? [Select Bouncers or Doormen] With Bouncers or Doormen Without Bouncers or Doormen Liability Section:   Desired Effective Date [Month] 01 02 03 04 05 06 07 08 09 10 11 12 [Day] 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 [Year] 2004 2005 Desired Coverage Limits [Select Coverage Limits] $100,000 / $300,000 $300,000 / $500,000 $500,000 / $1,000,000 $1,000,000 / $1,000,000 $1,000,000 / $2,000,000 Umbrella Policy Request Est. Annual Receipts Est. Annual Payroll Property Ownership [Select Property Ownership] Rent Owned / Mortgaged Owned / Not Mortgaged Year Built Total Square Footage Customer Square Footage                  Liquor Receipts $          Food Receipts: $          Property Section:   Construction Type [Select Construction Type] Frame Joisted Masonry Non-combustable Masonry Non-combustable Modified Resistive Fire Resistive / Superior Number of Stories [Select Number of Stories] 1 2 3 4 5 6 7 8 9 10 or More Burglar Alarm Type [Select Burglar Alarm Type] None Central / monitored Burglar Local Burglar Fire / Burglar Combination - monitored Fire / Burgular Combination - local only Other Fire Alarm Type [Select Fire Alarm Type] None Central / monitored Fire Local Fire Fire / Burglar Combination - monitored Fire / Burglar Combination - local only Smoke Other Fire Sprinklers ? [Select Fire Sprinklers] Yes No If Desired Coverage:   Building(s) Value ($) Bus Pers Property ($) Bus Income (incl EE) ($) Current Policy:   Current Insurance Co. [Select Insurance Company] None AIG Chubb CNA Fireman's Fund Hanover The Hartford Progressive Safeco St. Paul Travelers Zurich Other Expiring Premium ($) Years Without a Lapse [Select Years Without a Lapse] None 1 2 3 4 5 6 7 8 9 10 or More Claims in Last 3 Years [Select Number of Claims] None 1 2 3 or More

Property Coverage

Property coverage includes:

Building(s)* including:

• All garages, storage buildings and completed additions to the business
• Permanently installed fixtures, machinery and equipment
• Materials and supplies for construction or repair of the building
• Business Personal Property used for the maintenance and service of the building including fire extinguishing equipment, floor coverings, drapes and appliances
• Outdoor furniture

*Available if you own the building or your lease agreement requires you to insure it.

Business Personal Property including:

• Personal property
• Personal property of others
• Improvements and betterments
• Loss of income
• Valuable papers
• Accounts receivable
• Debris removal
• Emergency removal
• Newly acquired business personal property
• Property temporarily away from premises
• Outdoor trees, plants or shrubs
• Seasonal automatic increase
• Consequential loss
• Collapse of buildings

Optional Property Coverages:

Building glass Outdoor signs Electronic data processing equipment

Business Liability Coverage

Business Liability coverage includes:

• Premises and operations
• Premises medicals
• Products and completed operations
• Employers non-ownership
• Personal injury liability
• Broad form property damage
• Contractual liability
• Employees as additional insured
• Fire legal liability
• Medical expenses
• Supplementary payments

Optional Crime Coverage
(for additional premium)

Optional Crime coverage includes:

• Employee dishonesty
• Broad form money and securities - inside
• Broad form money and securities - outside
• Medical payments
• Forgery or alteration

Additional Coverages

• Building ordinance
• Commercial auto
• Umbrella coverage
• Equipment breakdown
• Earthquake coverage (in states where available)
• Workers' compensation (required if there are any employees on staff)

Business Life including:

• Simplified Employee Pension
• Qualified Pension Plan
• Tax-Sheltered Annuity Retirement Benefits
• Partnership Life Insurance
• Sole Proprietor Life Insurance
• Stockholder Life Insurance

The statements of coverage shown here are brief summaries and do not show policy exclusions. The policy should be read for your actual coverages and exclusions.

C.F.F. c/o © Kevin Osborne Insurance Agency
1419 Burlingame Avenue, Suite 0  |  Burlingame, California 94010
Phone: (650) 347~1717  |  Fax: (650) 347~1707
California License Number: 0777515