Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 185 (2011/09)
Restaurant / Tavern Supplement
ACORD 185, Restaurant / Tavern Supplement is used in conjunction
with ACORD 125, Commercial Insurance Application - Applicant Information Section.
This form is intended to be used as a supplement to the following forms, when insurance
is desired for restaurants, diners, banquet halls, taverns, night clubs, and other risks that
provide food and/or beverage service:
* ACORD 126, Commercial General Liability Section
* ACORD 140, Property Section
* ACORD 160, Business Owners Application
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION
Loc #
Enter number: The location number for the premises.
IDENTIFICATION SECTION
Bldg #
Enter number: The building number for the premises. Used when more than one building
exists at an individual location.
IDENTIFICATION SECTION
Date
Enter date: The month/day/year on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION
Agency
Enter text: The full name of the producer/agency.
IDENTIFICATION SECTION
Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If
required for self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the
policy commence.
IDENTIFICATION SECTION
Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy.
Use the actual name of the company within the group to which the policy has been issued.
This is not the insurer's group name or trade name.
IDENTIFICATION SECTION
NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION
Named Insured / Applicant's Name
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
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Section Name
Field Name
Field and/or Section Description
GENERAL RATING /
UNDERWRITING
Receipts Year 1
Enter year: The year the sales took place.
GENERAL RATING /
UNDERWRITING
Receipts Food 1
Enter amount: The annual gross receipts amount for food sales.
GENERAL RATING /
UNDERWRITING
Receipts Liquor 1
Enter amount: The annual gross receipts amount for liquor sales.
GENERAL RATING /
UNDERWRITING
% of Total Sales 1
Enter percentage: The percentage of receipts attributable to liquor sales.
GENERAL RATING /
UNDERWRITING
Receipts Other 1
Enter amount: The annual gross receipts amount for other products or services.
GENERAL RATING /
UNDERWRITING
Receipts Describe Other 1
Enter text: The description of other products or services.
GENERAL RATING /
UNDERWRITING
Receipts Year 2
Enter year: The year the sales took place.
GENERAL RATING /
UNDERWRITING
Receipts Food 2
Enter amount: The annual gross receipts amount for food sales.
GENERAL RATING /
UNDERWRITING
Receipts Liquor 2
Enter amount: The annual gross receipts amount for liquor sales.
GENERAL RATING /
UNDERWRITING
% of Total Sales 2
Enter percentage: The percentage of receipts attributable to liquor sales.
GENERAL RATING /
UNDERWRITING
Receipts Other 2
Enter amount: The annual gross receipts amount for other products or services.
GENERAL RATING /
UNDERWRITING
Receipts Describe Other 2
Enter text: The description of other products or services.
GENERAL RATING /
UNDERWRITING
Receipts Year 3
Enter year: The year the sales took place.
GENERAL RATING /
UNDERWRITING
Receipts Food 3
Enter amount: The annual gross receipts amount for food sales.
GENERAL RATING /
UNDERWRITING
Receipts Liquor 3
Enter amount: The annual gross receipts amount for liquor sales.
GENERAL RATING /
UNDERWRITING
% of Total Sales 3
Enter percentage: The percentage of receipts attributable to liquor sales.
GENERAL RATING /
UNDERWRITING
Receipts Other 3
Enter amount: The annual gross receipts amount for other products or services.
GENERAL RATING /
UNDERWRITING
Receipts Describe Other 3
Enter text: The description of other products or services.
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Section Name
Field Name
Field and/or Section Description
GENERAL RATING /
UNDERWRITING
Total Operating Expenses (Food
And Liquor Only)
Enter amount: The total operating expenses for food and liquor only. As used here, this is
for the most recent 12 month period.
GENERAL RATING /
UNDERWRITING
Total Operating Expenses (Other
Than Cost Of Food And Liquor)
Enter amount: The total operating expenses, other than for food and liquor. As used here,
this is for the most recent 12 month period.
GENERAL RATING /
UNDERWRITING
Net Profit Or Loss (If Loss, Attach
Financial Statement)
Enter amount: The net profit or loss amount. As used here, this is for the most recent 12
month period. If loss, attach a financial statement.
GENERAL RATING /
UNDERWRITING
Accounts Payable
Enter amount: The accounts payable amount. As used here, this is for the most recent 12
month period.
GENERAL RATING /
UNDERWRITING
Notes Payable (Not To Banks)
Enter amount: The total notes payable excluding banks. As used here, this is for the most
recent 12 month period.
GENERAL RATING /
UNDERWRITING
Bank Loads Payable
Enter amount: The total banks loans payable. As used here, this is for the most recent 12
month period.
GENERAL RATING /
UNDERWRITING
Restaurant Type - Deli
Check the box (if applicable): Indicates the nature of business is a deli.
GENERAL RATING /
UNDERWRITING
Bar
Check the box (if applicable): Indicates the nature of business is a bar.
GENERAL RATING /
UNDERWRITING
Tavern
Check the box (if applicable): Indicates the nature of business is a tavern.
GENERAL RATING /
UNDERWRITING
Fine Dining
Check the box (if applicable): Indicates the nature of business is a fine dining
establishment.
GENERAL RATING /
UNDERWRITING
Banquet Hall
Check the box (if applicable): Indicates the nature of business is a banquet hall.
GENERAL RATING /
UNDERWRITING
Fast Food
Check the box (if applicable): Indicates the nature of business is a fast food restaurant.
GENERAL RATING /
UNDERWRITING
Restaurant with Table Service
Check the box (if applicable): Indicates the nature of business is a restaurant with table
service.
GENERAL RATING /
UNDERWRITING
Restaurant without Table Service
Check the box (if applicable): Indicates the nature of business is a restaurant without table
service.
GENERAL RATING /
UNDERWRITING
Other
Check the box (if applicable): Indicates the restaurant type is other than those listed.
GENERAL RATING /
UNDERWRITING
Describe Other
Enter text: The description of the type of restaurant.
GENERAL RATING /
UNDERWRITING
Business Type - Franchised
Check the box (if applicable): Indicates the operations are franchised.
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Section Name
Field Name
Field and/or Section Description
GENERAL RATING /
UNDERWRITING
Not Franchised
Check the box (if applicable): Indicates the operations are not franchised.
GENERAL RATING /
UNDERWRITING
Private / Membership
Check the box (if applicable): Indicates the nature of business is private.
GENERAL RATING /
UNDERWRITING
Other
Check the box (if applicable): Indicates the nature of business is other than those listed.
GENERAL RATING /
UNDERWRITING
Describe Other
Enter text: The description of the nature/type of business.
GENERAL RATING /
UNDERWRITING
Seating Capacity
Enter number: The maximum seating capacity.
GENERAL RATING /
UNDERWRITING
Sunday - 24 Hour Operation ? (Y /
N)
Enter Y for a Yes response. Input N for No response. Indicates 24 hour operation.
GENERAL RATING /
UNDERWRITING
Opening Time
Enter time: The starting time for the normal business day. As used here, applies to
Sunday.
GENERAL RATING /
UNDERWRITING
Closing Time
Enter time: The closing time for the normal business day. As used here, applies to
Sunday.
GENERAL RATING /
UNDERWRITING
Entertainment Provided (Describe)
Enter text: The description of the type of entertainment provided.
GENERAL RATING /
UNDERWRITING
Monday - 24 Hour Operation ? (Y /
N)
Enter Y for a Yes response. Input N for No response. Indicates 24 hour operation. As
used here, applies to Monday.
GENERAL RATING /
UNDERWRITING
Opening Time
Enter time: The starting time for the normal business day. As used here, applies to
Monday.
GENERAL RATING /
UNDERWRITING
Closing Time
Enter time: The closing time for the normal business day.
GENERAL RATING /
UNDERWRITING
Entertainment Provided (Describe)
Enter text: The description of the type of entertainment provided.
GENERAL RATING /
UNDERWRITING
Tuesday - 24 Hour Operation ? (Y /
N)
Enter Y for a Yes response. Input N for No response. Indicates 24 hour operation.
GENERAL RATING /
UNDERWRITING
Opening Time
Enter time: The starting time for the normal business day. As used here, applies to
Tuesday
GENERAL RATING /
UNDERWRITING
Closing Time
Enter time: The closing time for the normal business day. As used here, applies to
Tuesday.
GENERAL RATING /
UNDERWRITING
Entertainment Provided (Describe)
Enter text: The description of the type of entertainment provided.
GENERAL RATING /
UNDERWRITING
Wednesday - 24 Hour Operation ?
(Y / N)
Enter Y for a Yes response. Input N for No response. Indicates 24 hour operation.
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Section Name
Field Name
Field and/or Section Description
GENERAL RATING /
UNDERWRITING
Opening Time
Enter time: The starting time for the normal business day. As used here, applies to
Wednesday.
GENERAL RATING /
UNDERWRITING
Closing Time
Enter time: The closing time for the normal business day. As used here, applies to
Wednesday.
GENERAL RATING /
UNDERWRITING
Entertainment Provided (Describe)
Enter text: The description of the type of entertainment provided.
GENERAL RATING /
UNDERWRITING
Thursday - 24 Hour Operation ? (Y
/ N)
Enter Y for a Yes response. Input N for No response. Indicates 24 hour operation.
GENERAL RATING /
UNDERWRITING
Opening Time
Enter time: The starting time for the normal business day. As used here, applies to
Thursday.
GENERAL RATING /
UNDERWRITING
Closing Time
Enter time: The closing time for the normal business day. As used here, applies to
Thursday.
GENERAL RATING /
UNDERWRITING
Entertainment Provided (Describe)
Enter text: The description of the type of entertainment provided.
GENERAL RATING /
UNDERWRITING
Friday - 24 Hour Operation ? (Y / N)
Enter Y for a Yes response. Input N for No response. Indicates 24 hour operation.
GENERAL RATING /
UNDERWRITING
Opening Time
Enter time: The starting time for the normal business day. As used here, applies to Friday.
GENERAL RATING /
UNDERWRITING
Closing Time
Enter time: The closing time for the normal business day. As used here, applies to Friday.
GENERAL RATING /
UNDERWRITING
Entertainment Provided (Describe)
Enter text: The description of the type of entertainment provided.
GENERAL RATING /
UNDERWRITING
Saturday - 24 Hour Operation ? (Y /
N)
Enter Y for a Yes response. Input N for No response. Indicates 24 hour operation.
GENERAL RATING /
UNDERWRITING
Opening Time
Enter time: The starting time for the normal business day. As used here, applies to
Saturday.
GENERAL RATING /
UNDERWRITING
Closing Time
Enter time: The closing time for the normal business day. As used here, applies to
Saturday.
GENERAL RATING /
UNDERWRITING
Entertainment Provided (Describe)
Enter text: The description of the type of entertainment provided.
GENERAL RATING /
UNDERWRITING
Catering / Banquet Operations
Check the box (if applicable): Indicates catering / banquet operations are provided.
GENERAL RATING /
UNDERWRITING
% Of Total Receipts
Enter percentage: The percentage of total receipts attributed to catering and / or banquet
operations.
GENERAL RATING /
UNDERWRITING
On Premises
Check the box (if applicable): Indicates catering / banquet operations are performed on the
property.
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Section Name
Field Name
Field and/or Section Description
GENERAL RATING /
UNDERWRITING
Off Premises
Check the box (if applicable): Indicates catering / banquet operations are performed off
premises.
GENERAL RATING /
UNDERWRITING
Describe Catering Operation
Enter text: The description of catering / banquet operations.
GENERAL RATING /
UNDERWRITING
Stairways
Check the box (if applicable): Indicates the building has stairways.
GENERAL RATING /
UNDERWRITING
Elevators
Check the box (if applicable): Indicates the building has elevators.
GENERAL RATING /
UNDERWRITING
Escalators
Check the box (if applicable): Indicates the building has escalators.
GENERAL RATING /
UNDERWRITING
Emergency Lighting Systems
Check the box (if applicable): Indicates the building has an emergency lighting system.
GENERAL RATING /
UNDERWRITING
Description
Enter text: The description of the emergency lighting system.
GENERAL RATING /
UNDERWRITING
Valet Parking by Employees
Check the box (if applicable): Indicates valet parking is performed on the property. As
used here, indicates that valet parking is performed by employees.
GENERAL RATING /
UNDERWRITING
Valet Parking by Third Party
Check the box (if applicable): Indicates valet parking is performed by a third party.
GENERAL RATING /
UNDERWRITING
Off Premises Parking
Check the box (if applicable): Indicates off premises parking is provided.
GENERAL RATING /
UNDERWRITING
Off Premises Parking Square
Footage
Enter number: The area, in square feet, of the off premises parking.
GENERAL RATING /
UNDERWRITING
If Yes, Address:
Enter text: The first address line of the off premises parking area.
GENERAL RATING /
UNDERWRITING
Enter text: The second address line of the off premises parking area.
GENERAL RATING /
UNDERWRITING
Enter text: The city of the off premises parking area.
GENERAL RATING /
UNDERWRITING
Enter code: The state or province of the off premises parking area.
GENERAL RATING /
UNDERWRITING
Enter code: The postal code of the off premises parking area.
GENERAL RATING /
UNDERWRITING
Garage Keepers Legal Liability
Required
Check the box (if applicable): Indicates garage keepers legal liability is required and
maintained for valet parking on the property.
GENERAL RATING /
UNDERWRITING
Certificate of Insurance Required
Check the box (if applicable): Indicates that a certificate of insurance is required/
maintained for valet parking by a third party.
ACORD 185 (2011/09) rev. 09-30-2011
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Section Name
Field Name
Field and/or Section Description
GENERAL RATING /
UNDERWRITING
Was the structure originally
designed for its current use?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Was the structure originally designed for its current use?
GENERAL RATING /
UNDERWRITING
If NO, describe
Enter text: The description of the original occupancy of the building.
GENERAL RATING /
UNDERWRITING
Has business been in operation
less than five (5) years at this
location?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Has business been in operation less than 5 years at this location? If yes,
describe prior experience of owner/manager..
GENERAL RATING /
UNDERWRITING
Date Current Management Started
Enter date: The date current management started at this location.
GENERAL RATING /
UNDERWRITING
Date Business Started at this
Location
Enter date: The date the business started at this location.
GENERAL RATING /
UNDERWRITING
Prior Experience of Owner /
Manager
Enter text: A description of the prior experience of the owner / manager.
GENERAL RATING /
UNDERWRITING
Any deliveries?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are there any deliveries?.
GENERAL RATING /
UNDERWRITING
# Company Vehicles Used
Enter number: The number of company vehicles used for deliveries.
GENERAL RATING /
UNDERWRITING
# Employee Vehicles Used
Enter number: The number of employee vehicles used for deliveries.
GENERAL RATING /
UNDERWRITING
Time Guarantee (Y / N)
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question Is there a time guarantee associated with deliveries?
GENERAL RATING /
UNDERWRITING
Time Guarantee Description
Enter text: A description of the time guarantee associated with deliveries.
GENERAL RATING /
UNDERWRITING
Radius of Delivery (miles)
Enter number: The radius distance of the delivery area, measured in miles.
GENERAL RATING /
UNDERWRITING
Sales % Delivery
Enter percentage: Percentage of sales attributable to deliveries.
GENERAL RATING /
UNDERWRITING
Sales % On-Premises
Enter percentage: Percentage of sales occurring on-premises.
GENERAL RATING /
UNDERWRITING
Are adequate emergency exits
provided and equipped with panic
hardware?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are adequate emergency exits provided and equipped with panic hardware?.
GENERAL RATING /
UNDERWRITING
Have adequate smoke alarms been
installed?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Have adequate smoke alarms been installed?.
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Section Name
Field Name
Field and/or Section Description
GENERAL RATING /
UNDERWRITING
Any other on or off premises
exposures not listed above?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are there any other on or off premises exposures not previously listed?.
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION
Loc #
Enter number: The location number for the premises.
IDENTIFICATION SECTION
Bldg #
Enter number: The building number for the premises. Used when more than one building
exists at an individual location.
COOKING / KITCHEN FIRE
PROTECTION
Grilling
Check the box (if applicable): Indicates grilling is performed on the property.
COOKING / KITCHEN FIRE
PROTECTION
Deep Fat Frying
Check the box (if applicable): Indicates deep fat frying is performed on the property.
COOKING / KITCHEN FIRE
PROTECTION
Open Broiling
Check the box (if applicable): Indicates open broiling is performed on the property.
COOKING / KITCHEN FIRE
PROTECTION
Cooks with Solid Fuel
Check the box (if applicable): Indicates that solid fuel cooking is performed on premises.
As used here, indicates that cooking with solid fuel is done on premises.
COOKING / KITCHEN FIRE
PROTECTION
Roasting
Check the box (if applicable): Indicates roasting is performed on the property.
COOKING / KITCHEN FIRE
PROTECTION
Tableside Cooking
Check the box (if applicable): Indicates tableside cooking is performed on the property.
COOKING / KITCHEN FIRE
PROTECTION
Barbecue
Check the box (if applicable): Indicates barbequing is performed on the property.
COOKING / KITCHEN FIRE
PROTECTION
Other
Check the box (if applicable): Indicates features of, or performed on, the property exist
other than those listed.
COOKING / KITCHEN FIRE
PROTECTION
Describe Other
Enter text: The description of a feature of, or performed on, the property.
KITCHEN FIRE
PROTECTION
U.L. 300 Approved automatic
extinguishing system covers all
cooking surfaces
Check the box (if applicable): Indicates a U.L. 300 approved automatic fire extinguishing
system covers all cooking surfaces.
KITCHEN FIRE
PROTECTION
U.L. 300 Approved automatic
extinguishing system under
maintenance contract
Check the box (if applicable): Indicates the U.L. 300 approved automatic fire extinguishing
system is under a maintenance contract.
KITCHEN FIRE
PROTECTION
Number of Months
Enter number: The frequency of the maintenance service visits for the U.L. 300 approved
automatic fire extinguishing system, in months.
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Section Name
Field Name
Field and/or Section Description
KITCHEN FIRE
PROTECTION
Automatic Gas or Electric shut offs
for cooking
Check the box (if applicable): Indicates there are automatic gas or electric shut offs for
cooking.
KITCHEN FIRE
PROTECTION
Hood and Filters cleaned weekly
by staff
Check the box (if applicable): Indicates hoods and filters are cleaned weekly by staff.
KITCHEN FIRE
PROTECTION
BC and K Extinguishers Available
in Kitchen
Check the box (if applicable): Indicates BC and K extinguishers are available in the
kitchen.
KITCHEN FIRE
PROTECTION
Hoods and Ducts over all cooking
equipment
Check the box (if applicable): Indicates if hoods and ducts are over all cooking equipment.
KITCHEN FIRE
PROTECTION
Hoods and Ducts maintenance
contract schedule
Check the box (if applicable): Indicates if there is a maintenance contract for the hoods
and ducts.
KITCHEN FIRE
PROTECTION
# Months:
Enter number: The frequency of the maintenance service visits for the hoods and ducts, in
months.
KITCHEN FIRE
PROTECTION
Adequate clearance between
Hoods, Ducts, Cooking Equipment
and Combustible Materials
Check the box (if applicable): Indicates there is adequate clearance between hoods, ducts,
cooking equipment and combustible materials.
SPOILAGE INFORMATION
Is there a Refrigerator / Freezer,
Walk-in or otherwise on site for
cold storage?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is there a refrigerator/freezer, walking-in or otherwise, on site for cold storage of
food and beverages?
SPOILAGE INFORMATION
How long can refrigerated spaces
hold the temperature required
before contents spoil?
Enter number: The number of hours refrigerated spaces can hold the temperature required
before contents spoil.
SPOILAGE INFORMATION
Does the refrigeration system
utilized have any spare capacity?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is the refrigeration system utilized have any spare capacity?
SPOILAGE INFORMATION
Remarks
Enter text: An explanation as to whether the refrigeration system used has any spare
capacity.
SPOILAGE INFORMATION
Is there a written service /
maintenance contract for all
refrigeration / cooling equipment?
(If YES, attach copy of contract)
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is there a written service/maintenance contract for all refrigeration/cooling
equipment?
SPOILAGE INFORMATION
Does a contingency plan exist in
the event there is a loss of
refrigeration?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, does a contingency plan exist in the event there is a loss of refrigeration?
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Section Name
Field Name
Field and/or Section Description
SPOILAGE INFORMATION
Alternative Power Source
(checkbox)
Check the box (if applicable): Indicates the contingency plan in the event of loss of
refrigeration is a an alternative power source.
SPOILAGE INFORMATION
Temporary Storage Location
(checkbox)
Check the box (if applicable): Indicates there contingency plan in the event of loss of
refrigeration is a temporary storage location.
SPOILAGE INFORMATION
Other (checkbox)
Check the box (if applicable): Indicates the contingency plan in the event of loss of
refrigeration is other than the items listed.
SPOILAGE INFORMATION
Describe
Enter text: The description of the contingency plan.
SPOILAGE INFORMATION
Do refrigerated spaces have
temperature alarms (high / low)
installed? (If YES, indicate
where they alarm)
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Do refrigerated spaces have temperature alarms (high/low) installed?
SPOILAGE INFORMATION
Local (checkbox)
Check the box (if applicable): Indicates the refrigerated spaces have a local temperature
alarm installed.
SPOILAGE INFORMATION
Paging (checkbox)
Check the box (if applicable): Indicates the refrigerated spaces have a paging temperature
alarm installed.
SPOILAGE INFORMATION
Central (checkbox)
Check the box (if applicable): Indicates the refrigerated spaces have a central temperature
alarm installed.
SPOILAGE INFORMATION
Other (checkbox)
Check the box (if applicable): Indicates the refrigerated spaces have temperature alarms
installed that are other than those listed.
SPOILAGE INFORMATION
Describe
Enter text: The description of the other temperature alarms.
SPOILAGE INFORMATION
Is ammonia used as a refrigerant?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, is ammonia used as a refrigerant?
SPOILAGE INFORMATION
Spare Capacity # of tons
Enter number: If ammonia is used as a refrigerant, the spare capacity in number of tons.
SPOILAGE INFORMATION
Are ammonia sensing devices in
each refrigerated space?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are ammonia sensing devices in each refrigerated spaces?
SPOILAGE INFORMATION
Is automatic shutoff tied to a
sensing system?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is automatic shutoff tied to sensing system?
SPOILAGE INFORMATION
Can refrigerated spaces be
isolated from one to another in the
event of an ammonia leak?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Can refrigerated spaces be isolated from one another in the even of an
ammonia leak?
SPOILAGE INFORMATION
Remarks
Enter text: An explanation as to whether refrigerated spaces can be isolated from one
another in the even of an ammonia leak.
LIQUOR INFORMATION
Liquor License Number
Enter identifier: The liquor license number.
LIQUOR INFORMATION
Liquor License Type
Enter text: The class or type of liquor license.
LIQUOR INFORMATION
Number of Bars on Premises
Enter number: The number of bars on the premises.
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Section Name
Field Name
Field and/or Section Description
LIQUOR INFORMATION
Number of Bartenders
Enter number: The number of bartenders on the premises.
LIQUOR INFORMATION
Number of Waiters / Waitresses
Enter number: The number waiters and / or waitresses on the premises.
LIQUOR INFORMATION
Average Length of Employment
Enter number: The average length of employment, in months.
LIQUOR INFORMATION
Are there beer / wine sales only?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, are there wine/ beer sales only?
LIQUOR INFORMATION
Is there a full bar?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is there a full bar?
LIQUOR INFORMATION
Is there a happy hour, or drink
specials or special promotions?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is there a happy hour, or drink specials or similar promotions?
LIQUOR INFORMATION
Are patrons allowed to bring
alcohol on the premises?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are patrons allowed to bring alcohol on premises?
LIQUOR INFORMATION
Do employees check identification
of patrons prior to serving
alcohol?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Do employees check identification of patrons prior to serving or selling alcohol?
LIQUOR INFORMATION
Is there a written policy on serving
alcohol to employees and
customers?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question Is there a written policy on serving alcohol to employees and customers?
LIQUOR INFORMATION
Is management notifed prior to
refusing to serve patrons?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is management notified prior to refusing to serve patrons?
LIQUOR LIABILITY
Is Documentation kept on each
incident?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is documentation kept on each incident of shutting off patrons?.
LIQUOR INFORMATION
Are Employees given Liquor
Training / Certification Courses?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are employees given liquor training/certification courses? As used here, if yes,
explain type and when trained.
LIQUOR INFORMATION
If Yes, Explain type and when
trained
Enter text: The description of the other training.
LIQUOR INFORMATION
# of Alcohol Servers who have
completed TIPS Intervention
courses or equivalent
Enter number: The number of alcohol servers who have completed TIPS (Training for
Intervention Procedures) intervention courses or equivalent.
LIQUOR INFORMATION
Are all Alcohol Servers currently
TIPS or TAM certified (Y / N)
Enter Y for a Yes response. Input N for No response. Indicates if alcohol servers
currently certified. As used here, indicates if all Alcohol Servers are currently TIPS or TAM
certified.
LIQUOR INFORMATION
Have there been any Liquor Board
Violations? (If YES, list all
violations)
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Have there been any liquor board violations?.
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Section Name
Field Name
Field and/or Section Description
LIQUOR INFORMATION
Date of Occurrence - 1
Enter date: The date of occurrence associated with the liquor board warning or violation.
LIQUOR INFORMATION
Explanation
Enter text: The explanation for the answer to the liquor board warning or violation. As used
here, if yes, list all violations.
LIQUOR INFORMATION
Resolution
Enter text: The resolution associated with the liquor board warning or violation.
LIQUOR INFORMATION
Date of Resolution
Enter date: The resolution associated with the liquor board warning or violation.
LIQUOR INFORMATION
Date of Occurrence - 2
Enter date: The date of occurrence associated with the liquor board warning or violation.
LIQUOR INFORMATION
Explanation
Enter text: The explanation for the answer to the liquor board warning or violation.
LIQUOR INFORMATION
Resolution
Enter text: The resolution associated with the liquor board warning or violation.
LIQUOR INFORMATION
Date of Resolution
Enter date: The resolution associated with the liquor board warning or violation.
LIQUOR INFORMATION
Are facilites available for use or
rent for private parties, receptions,
banquets or similar affairs?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are facilities available for use or rent for private parties, receptions, banquets or
similar affairs?
LIQUOR INFORMATION
Number of times per yesr
Enter number: The number of events per year.
LIQUOR INFORMATION
Do you subscribe to a taxi or other
service providing transportation
home to apparently intoxicated
patrons?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Do you subscribe to a taxi or other service providing transportation home to
apparently intoxicated patrons?
LIQUOR INFORMATION
Remarks
Enter text: An explanation as to whether you subscribe to a taxi or other service that
provides transportation home to apparently intoxicated patrons.
LIQUOR INFORMATION
Do you or your employees provide
transportation home to apparently
intoxicated patrons?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Do you or employees provide transportation home to apparently intoxicated
patrons?
LIQUOR INFORMATION
Remarks
Enter text: An explanation as to whether employees provide transportation home for
apparently intoxicated patrons.
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION
Loc #
Enter number: The location number for the premises.
IDENTIFICATION SECTION
Bldg #
Enter number: The building number for the premises. Used when more than one building
exists at an individual location.
BAR / TAVERN /
NIGHTCLUB INFORMATION Live music
Check the box (if applicable): Indicates a band is provided for entertainment. As used
here, includes any type of live music.
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Section Name
Field Name
Field and/or Section Description
BAR / TAVERN /
NIGHTCLUB INFORMATION Describe
Enter text: The description of the type of entertainment provided. As used here, includes
any type of live music.
BAR / TAVERN /
NIGHTCLUB INFORMATION Dancing
Check the box (if applicable): Indicates dancing is permitted on the premises.
BAR / TAVERN /
NIGHTCLUB INFORMATION Dance Contests
Check the box (if applicable): Indicates dancing contests are provided for entertainment.
BAR / TAVERN /
NIGHTCLUB INFORMATION DJ (check box)
Check the box (if applicable): Indicates a disc jockey is provided for entertainment.
BAR / TAVERN /
NIGHTCLUB INFORMATION Karaoke
Check the box (if applicable): Indicates karaoke is provided for entertainment.
BAR / TAVERN /
NIGHTCLUB INFORMATION Juke Box
Check the box (if applicable): Indicates a juke box is provided for entertainment.
BAR / TAVERN /
NIGHTCLUB INFORMATION Piano
Check the box (if applicable): Indicates a piano is provided for entertainment.
BAR / TAVERN /
NIGHTCLUB INFORMATION Other (Describe) (check box)
Check the box (if applicable): Indicates a form of entertainment is provided other than
those listed.
BAR / TAVERN /
NIGHTCLUB INFORMATION Describe
Enter text: The description of the type of entertainment provided.
BAR / TAVERN /
NIGHTCLUB INFORMATION Dance Floor Square Feet
Enter number: The area of the dance floor in square feet.
BAR / TAVERN /
NIGHTCLUB INFORMATION N)
Is a dance permit maintained? (Y /
Enter Y for a Yes response. Input N for No response. Indicates if a dance permit is
maintained.
BAR / TAVERN /
NIGHTCLUB INFORMATION Under 21 (check box)
Check the box (if applicable): Indicates the age range of the business clientele is under
twenty one years old.
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Section Name
Field Name
Field and/or Section Description
BAR / TAVERN /
NIGHTCLUB INFORMATION 21 - 25
Check the box (if applicable): Indicates the average age of the business clientele is
between 21 and 25.
BAR / TAVERN /
NIGHTCLUB INFORMATION 26 - 30
Check the box (if applicable): Indicates the average age of the business clientele is
between 26 and 30.
BAR / TAVERN /
NIGHTCLUB INFORMATION 31 - 65
Check the box (if applicable): Indicates the average age of the business clientele is
between 31 and 65.
BAR / TAVERN /
NIGHTCLUB INFORMATION Over 65
Check the box (if applicable): Indicates the average age of the business clientele is over
65.
BAR / TAVERN /
NIGHTCLUB INFORMATION Pool Tables Count
Enter number: The number of pool tables.
BAR / TAVERN /
NIGHTCLUB INFORMATION Dart Boards Count
Enter number: The number of dart boards.
BAR / TAVERN /
NIGHTCLUB INFORMATION Pinball Machines Count
Enter number: The number of pin ball machines.
BAR / TAVERN /
NIGHTCLUB INFORMATION Gambling Devices Count
Enter number: The number of gambling devices.
BAR / TAVERN /
NIGHTCLUB INFORMATION Poker Tables / Dealers Count
Enter number: The number of poker tables.
BAR / TAVERN /
NIGHTCLUB INFORMATION Video / Electronic Games Count
Enter number: The number of video games.
BAR / TAVERN /
NIGHTCLUB INFORMATION Description
Video / Electronic Games
Enter text: The description of video games provided.
BAR / TAVERN /
NIGHTCLUB INFORMATION Mechanical Devices Count
Enter number: The number of mechanical amusement devices.
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Section Name
Field Name
Field and/or Section Description
BAR / TAVERN /
NIGHTCLUB INFORMATION Mechanical Devices Description
Enter text: The description of mechanical amusement devices provided.
BAR / TAVERN /
NIGHTCLUB INFORMATION Other Amusement Devices
Enter text: The type of amusement device.
BAR / TAVERN /
NIGHTCLUB INFORMATION Other Amusement Devices Count
Enter number: The number of amusement devices.
BAR / TAVERN /
NIGHTCLUB INFORMATION Description
Other Amusement Devices
Enter text: The description of the amusement devices.
BAR / TAVERN /
NIGHTCLUB INFORMATION Other Amusement Devices
Enter text: The type of amusement device.
BAR / TAVERN /
NIGHTCLUB INFORMATION Other Amusement Devices Count
Enter number: The number of amusement devices.
BAR / TAVERN /
NIGHTCLUB INFORMATION Description
Other Amusement Devices
Enter text: The description of the amusement devices.
BAR / TAVERN /
NIGHTCLUB INFORMATION Other Amusement Devices
Enter text: The type of amusement device.
BAR / TAVERN /
NIGHTCLUB INFORMATION Other Amusement Devices Count
Enter number: The number of amusement devices.
BAR / TAVERN /
NIGHTCLUB INFORMATION Description
Other Amusement Devices
Enter text: The description of the amusement devices.
BAR / TAVERN /
NIGHTCLUB INFORMATION Is there a stage?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is there a stage?
BAR / TAVERN /
NIGHTCLUB INFORMATION Remarks
Enter text: An explanation as to whether there is a stage.
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Section Name
Field Name
Field and/or Section Description
BAR / TAVERN /
NIGHTCLUB INFORMATION Is there special equipment?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is there special equipment?
BAR / TAVERN /
NIGHTCLUB INFORMATION Remarks
Enter text: An explanation as to whether there is special equipment.
BAR / TAVERN /
NIGHTCLUB INFORMATION Are there pyrotechnics?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are there pyrotechnics?
BAR / TAVERN /
NIGHTCLUB INFORMATION Remarks
Enter text: An explanation as to whether there are pyrotechnics.
BAR / TAVERN /
NIGHTCLUB INFORMATION participation?
Is there a recreation area or other
activities that would include patron
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is there a recreation area or other activities that would include patron
participation (such as wrestling, boxing, volleyball, basket ball, etc)?
BAR / TAVERN /
NIGHTCLUB INFORMATION Remarks
Enter text: An explanation as to whether there is an recreation area or other activities that
would include patron participation (such as wrestling, boxing, volley ball, basket ball, etc.)?
BAR / TAVERN /
NIGHTCLUB INFORMATION Are shots specials offered?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are shot specials offered?
BAR / TAVERN /
NIGHTCLUB INFORMATION Is there a steady bar clientelle?
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Is there steady bar clientele?
BAR / TAVERN /
NIGHTCLUB INFORMATION on employees?
Are background checks conducted
Enter Y for a Yes response. Input N for No response. Indicates the response to the
question, Are background checks done on employees?
BAR / TAVERN /
NIGHTCLUB INFORMATION Remarks
Enter text: An explanation as to whether background checks are conduced on employees.
BAR / TAVERN /
NIGHTCLUB INFORMATION Employees
Bouncers: Number Unarmed
Enter number: The number of unarmed employee bouncers
BAR / TAVERN /
NIGHTCLUB INFORMATION Number Armed Employees
Enter number: The number of armed employee bouncers.
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Section Name
Field Name
Field and/or Section Description
BAR / TAVERN /
NIGHTCLUB INFORMATION Number Unarmed Contractors
Enter number: The number of armed contractor bouncers
BAR / TAVERN /
NIGHTCLUB INFORMATION Number Armed Contractors
Enter number: The number of armed contractor bouncers.
BAR / TAVERN /
NIGHTCLUB INFORMATION Employees
Doormen: Number Unarmed
Enter number: The number of unarmed employee doormen.
BAR / TAVERN /
NIGHTCLUB INFORMATION Number Armed Employees
Enter number: The number of armed employee doormen.
BAR / TAVERN /
NIGHTCLUB INFORMATION Number Unarmed Contractors
Enter number: The number of unarmed contractor doormen.
BAR / TAVERN /
NIGHTCLUB INFORMATION Number Armed Contractors
Enter number: The number of armed contractor doormen.
BAR / TAVERN /
NIGHTCLUB INFORMATION Employees
Parking Patrol: Number Unarmed
Enter number: The number of unarmed employee parking patrol.
BAR / TAVERN /
NIGHTCLUB INFORMATION Number Armed Employees
Enter number: The number of armed employee parking patrol.
BAR / TAVERN /
NIGHTCLUB INFORMATION Number Unarmed Contractors
Enter number: The number of unarmed contractor parking patrol.
BAR / TAVERN /
NIGHTCLUB INFORMATION Number Armed Contractors
Enter number: The number of armed contractor parking patrol.
REMARKS
Remarks
Enter text: The remarks associated with the general liability line of business. Use this
section to provide any additional information required for underwriting or rating. ACORD
101, Additional Remarks Schedule, may be attached if more space is required.
ATTACHMENTS
Financial Statement
Check the box (if applicable): Indicates that a financial statement is attached to the policy.
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Section Name
Field Name
Field and/or Section Description
ATTACHMENTS
Photos
Check the box (if applicable): Indicates a photograph is attached to the policy.
ATTACHMENTS
Other Attachment
Check the box (if applicable): Indicates there is an attachment other than those listed on
the application.
ATTACHMENTS
Other Attachment Description
Enter text: The description of the type of other attachment.
ATTACHMENTS
Other Attachment
Check the box (if applicable): Indicates there is an attachment other than those listed on
the application.
ATTACHMENTS
Other Attachment Description
Enter text: The description of the type of other attachment.
ATTACHMENTS
Other Attachment
Check the box (if applicable): Indicates there is an attachment other than those listed on
the application.
ATTACHMENTS
Other Attachment Description
Enter text: The description of the type of other attachment.
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g.
agency or brokerage).
IDENTIFICATION SECTION
Loc #
Enter number: The location number for the premises.
IDENTIFICATION SECTION
Bldg #
Enter number: The building number for the premises. Used when more than one building
exists at an individual location.
REMARKS
Remarks
Enter text: The remarks associated with the general liability line of business. Use this
section to provide any additional information required for underwriting or rating. ACORD
101, Additional Remarks Schedule, may be attached if more space is required.
SIGNATURE
Applicant Named Insured Name
(print)
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
SIGNATURE
Applicant Named Insured
Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
SIGNATURE
Applicant Named Insured Name
(print)
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
SIGNATURE
Applicant Named Insured
Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
SIGNATURE
Applicant Named Insured Name
(print)
Enter text: The named insured(s) as it/they will appear on the policy declarations page.
SIGNATURE
Applicant Named Insured
Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE
Date
Enter date: The date the form was signed by the named insured.
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Section Name
Field Name
Field and/or Section Description
Edition
Date
The edition identifier of the form including the form number and edition (the date is typically
formatted YYYY/MM).
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