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ACORD 185 (2007/05) 1 of 8
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Section Name |
Field Name |
Field and/or Section Description |
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Use ACORD 185, Restaurant/Tavern Supplement, 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. |
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This form is used in conjunction with: |
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* ACORD 125, Commercial Insurance Application |
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* ACORD 126, Commercial General Liability Section |
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TITLE |
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* ACORD 140, Property Section |
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ACORD 185 (2007/05) |
Restaurant/Tavern Supplement |
* ACORD 160, Business Owners Application |
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IDENTIFICATION SECTION |
Agency Customer ID |
Customer's identification number assigned by the agency. |
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IDENTIFICATION SECTION |
LOC # |
Location number of premises as it appears on ACORD 125. |
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IDENTIFICATION SECTION |
Date |
Month/day/year (MM/DD/YYYY) in which the form is completed. |
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IDENTIFICATION SECTION |
Agency |
Agency's name. |
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IDENTIFICATION SECTION |
Named Insured/Applicant's Name |
Full name of the applicant as it appears on ACORD 125. |
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IDENTIFICATION SECTION |
Policy Number |
Provide the policy number if a policy has already been issued. |
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Name of the applicable insurance company. Do not use group names; use the actual |
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IDENTIFICATION SECTION |
Company Name |
name of the company within the group which issued the policy or will issue the policy. |
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IDENTIFICATION SECTION |
NAIC Code |
Individual company code assigned by the NAIC. |
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GENERAL |
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RATING/UNDERWRITING |
Location of Property |
Provide the street address as it appears on ACORD 125. |
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GENERAL |
Type Of Business - Check all that |
Identify the type of business conducted. If "Other", describe. Also check the appropriate |
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RATING/UNDERWRITING |
apply |
boxes to indicate if the business is franchised, not franchised, seasonal or year round. |
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GENERAL |
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RATING/UNDERWRITING |
Number of Employees - Full Time |
Indicate the total number of full time employees. |
ACORD 185 (2007/05) 2 of 8
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Section Name |
Field Name |
Field and/or Section Description |
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GENERAL |
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RATING/UNDERWRITING |
Number of Employees - Part Time |
Indicate the total number of part time employees. |
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GENERAL |
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RATING/UNDERWRITING |
Square Footage - Total Building |
Enter the square footage for the total building. |
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GENERAL |
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RATING/UNDERWRITING |
Square Footage - Restaurant |
Enter the square footage for the restaurant. |
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GENERAL |
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RATING/UNDERWRITING |
Square Footage - Apartments |
Enter the square footage for all apartments. |
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GENERAL |
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RATING/UNDERWRITING |
Number of Apartments |
Enter the total number of apartment units. |
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GENERAL |
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RATING/UNDERWRITING |
Seating Capacity |
Enter the maximum seating capacity |
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GENERAL |
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RATING/UNDERWRITING |
Hours of Operation |
Provide the hours of operation. |
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GENERAL |
Original Use and Subsequent |
Indicate what the building was originally used for and any subsequent occupancies of the |
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RATING/UNDERWRITING |
Occupancies of the Building |
premises. |
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GENERAL |
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Indicate the receipts for the past three years for food, liquor and other revenue. Provide |
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RATING/UNDERWRITING |
Receipts (Last 3 Years) |
the year and if "Other", identify in the space provided. |
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GENERAL |
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RATING/UNDERWRITING |
Food |
Indicate the total annual receipts for food. |
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GENERAL |
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RATING/UNDERWRITING |
Liquor |
Indicate the total annual receipts for liquor. |
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GENERAL |
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RATING/UNDERWRITING |
Other |
Indicate the total annual "Other" receipts. Identify in the space provided. |
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GENERAL |
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RATING/UNDERWRITING |
Check all that apply |
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GENERAL |
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RATING/UNDERWRITING |
Stairway(s) |
Check this box if the property has any stairways. |
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GENERAL |
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RATING/UNDERWRITING |
Elevator(s) |
Check this box if the property has any elevators. |
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GENERAL |
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RATING/UNDERWRITING |
Escalator(s) |
Check this box if the property has any escalators. |
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GENERAL |
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RATING/UNDERWRITING |
Grilling |
Check this box if any grilling is performed on the property. |
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GENERAL |
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RATING/UNDERWRITING |
Deep Fat Frying |
Check this box if any deep fat frying is performed on the property. |
ACORD 185 (2007/05) 3 of 8
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Section Name |
Field Name |
Field and/or Section Description |
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GENERAL |
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RATING/UNDERWRITING |
Open Broiling |
Check this box if any open broiling is performed on the property. |
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GENERAL |
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RATING/UNDERWRITING |
Roasting |
Check this box if any roasting is performed on the property. |
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GENERAL |
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RATING/UNDERWRITING |
Tableside Cooking |
Check this box if any tableside cooking is performed on the property. |
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GENERAL |
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Check this box to indicate any option not previously defined. Decribe in the space |
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RATING/UNDERWRITING |
Blank Check Box |
provided. |
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GENERAL |
Emergency Lighting Systems |
Check this box if the property has any emergency lighting systems. Describe in the space |
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RATING/UNDERWRITING |
(Describe) |
provided. |
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Check this box if any non-owned automobiles are used for business purposes. If non- |
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GENERAL |
Non-Owned Automobiles - Number |
owned automobiles are used for business purposes, indicate the number of employees |
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RATING/UNDERWRITING |
of Employees |
using their own vehicles. |
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GENERAL |
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RATING/UNDERWRITING |
Valet Parking |
Check this box if valet parking is performed on the property. |
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GENERAL |
Woodburning Stove or Fireplace |
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RATING/UNDERWRITING |
Insert |
Check this box if there are any woodburning stoves or fireplace inserts on the property. |
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GENERAL |
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If there are any woodburning stoves or fireplace inserts on the property, indicate the date |
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RATING/UNDERWRITING |
Date Installed |
installed. |
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GENERAL |
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If there are any woodburning stoves or fireplace inserts on the property, indicate the name |
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RATING/UNDERWRITING |
Manufacturer Name |
of the manufacturer. |
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Garage Keepers Legal Liability |
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GENERAL |
Required/Maintained for Valet |
Check this box if Garage Keepers Legal Liability is required and maintained for valet |
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RATING/UNDERWRITING |
Parking |
parking on the property |
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GENERAL |
Property has been designated an |
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RATING/UNDERWRITING |
historical marker |
Check this box if the property has been designated an historical marker |
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GENERAL |
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RATING/UNDERWRITING |
Off Premises Parking |
Check this box if off premises parking is provided. |
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GENERAL |
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RATING/UNDERWRITING |
Square Footage |
If off premises parking is provided, indicate the total square footage. |
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GENERAL |
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RATING/UNDERWRITING |
Address |
If off premises parking is provided, provide the full address. |
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GENERAL |
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RATING/UNDERWRITING |
Catering/Banquet Operations |
Check this box if catering and/or banquet operations are performed on the property. |
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GENERAL |
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If catering and/or banquet operations are performed on the property, indicate the percent |
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RATING/UNDERWRITING |
% of Total Receipts |
of total receipts for that operation. |
ACORD 185 (2007/05) 4 of 8
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Section Name |
Field Name |
Field and/or Section Description |
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GENERAL |
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RATING/UNDERWRITING |
On Premises |
Check this box if the catering and/or banquet operations are performed on the property. |
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GENERAL |
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RATING/UNDERWRITING |
Off Premises |
Check this box if the catering and/or banquet operations are performed off premises. |
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GENERAL |
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RATING/UNDERWRITING |
Describe |
Describe the catering and/or banquet operations. |
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GENERAL |
Explain all "YES" responses |
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RATING/UNDERWRITING |
unless stated otherwise |
Enter Y for a "YES" response. Enter N for a "NO" response. |
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1. Has applicant now or in the |
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past been involved in bankruptcy, |
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GENERAL |
foreclosure, tax lien, business |
If "YES", provide specific details surrounding the circumstances involved in the |
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RATING/UNDERWRITING |
failure, or any litigation? |
bankruptcy, foreclosure, tax lien, business failure or litigation. |
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GENERAL |
2. Has business been in operation |
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RATING/UNDERWRITING |
less than 5 years at this location? |
If "YES", describe prior experience of owner/manager. |
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GENERAL |
3. Are there lodging operations |
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RATING/UNDERWRITING |
other than apartments? |
If "YES", describe the type of lodging operations. |
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GENERAL |
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RATING/UNDERWRITING |
4. Any deliveries? |
If "YES", describe the nature of the deliveries. |
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5. Are adequate emergency exits |
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GENERAL |
provided and equipped with panic |
Indicate by Y for a "YES" response or N for a "NO" response, if there are adequate |
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RATING/UNDERWRITING |
hardware? |
emergency exits provided and equipped with panic hardware. |
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GENERAL |
6. Have adequate smoke alarms |
Indicate by Y for a "YES" response or N for a "NO" response, if adequate smoke alarms |
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RATING/UNDERWRITING |
been installed? |
have been installed. |
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GENERAL |
7. Any other on or off premises |
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RATING/UNDERWRITING |
exposures not listed above? |
If "YES", describe any exposures not previously identified. |
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This section is intended to provide sufficient information about the cooking equipment fire |
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KITCHEN FIRE |
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protection maintenance, and installation to enable the underwriter to assess the risks |
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PROTECTION |
Check all that apply |
involved. Use the Remarks section to provide additional information. |
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U.L. 300 Approved Automatic |
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KITCHEN FIRE |
Extinguishing System Covers All |
Check this box if an U.L. 300 approved Automatic Extinguishing System covers all |
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PROTECTION |
Cooking Surfaces |
cooking surfaces. |
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KITCHEN FIRE |
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PROTECTION |
Name of System |
Indicate the name of the U.L. 300 approved Automatic Extinguishing System. |
ACORD 185 (2007/05) 5 of 8
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Section Name |
Field Name |
Field and/or Section Description |
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KITCHEN FIRE |
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PROTECTION |
Wet |
Check this box if the U.L. 300 approved Automatic Extinguishing System is a wet system. |
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KITCHEN FIRE |
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PROTECTION |
Dry |
Check this box if the U.L. 300 approved Automatic Extinguishing System is a dry system. |
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U.L. 300 Approved Automatic |
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KITCHEN FIRE |
Extinguishing System |
Check this box if the U.L. 300 approved Automatic Extinguishing System is under a |
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PROTECTION |
Maintenance Contract |
maintenance contract. |
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KITCHEN FIRE |
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If there is a maintenance contract for the U.L. 300 approved Automatic Extinguishing |
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PROTECTION |
# months |
System, indicate the frequency of the maintenance service visits, in months. |
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KITCHEN FIRE |
Automatic Gas or Electric Shut |
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PROTECTION |
Offs for Cooking |
Check this box if there are automatic gas or electric shut offs for cooking. |
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KITCHEN FIRE |
Hood and Filters Cleaned Weekly |
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PROTECTION |
by Staff |
Check this box if hood and filters are cleaned weekly by staff. |
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KITCHEN FIRE |
BC and K Extinguishers Available |
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PROTECTION |
in Kitchen |
Check this box if BC and K extinguishers are available in kitchen. |
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KITCHEN FIRE |
Hoods and Ducts Over All Cooking |
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PROTECTION |
Equipment |
Check this box if hoods and ducts are over all cooking equipment. |
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KITCHEN FIRE |
Hoods and Ducts Maintenance |
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PROTECTION |
Contract Schedule |
Check this box if there is a maintenance contract for the hoods and ducts. |
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KITCHEN FIRE |
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If there is a maintenance contract for the hoods and ducts, indicate the frequency of the |
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PROTECTION |
# of Months |
maintenance service visits, in months. |
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Adequate Clearance between |
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KITCHEN FIRE |
Hoods, Ducts, Cooking Equipment |
Check this box if there is adequate clearance between hoods, ducts, cooking equipment |
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PROTECTION |
and Combustible Materials |
and combustible materials. |
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Use this section to provide information about the financial condition of the business during |
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the most recent 12 month period. It is not necessary to complete this section if adequate |
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FINANCIAL INFORMATION |
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financial statements are attached. |
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Total Operating Expenses (Food |
Indicate the total operating expenses for food and liquor only for the most recent 12 month |
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FINANCIAL INFORMATION |
and Liquor Only) |
period. |
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Total Operating Expenses (Other |
Indicate the total operating expenses, other than for food and liquor, for the most recent |
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FINANCIAL INFORMATION |
than Cost of Food and Liquor) |
12 month period. |
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Net Profit or Loss (If Loss, Attach |
Indicate the net profit or loss for the most recent 12 month period. If loss, attach a |
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FINANCIAL INFORMATION |
Financial Statement) |
financial statement. |
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FINANCIAL INFORMATION |
Accounts Payable |
Indicate the total accounts payable for the past 12 month period. |
ACORD 185 (2007/05) 6 of 8
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Section Name |
Field Name |
Field and/or Section Description |
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FINANCIAL INFORMATION |
Notes Payable (Not to Banks) |
Indicate the total notes payable excluding banks for the most recent 12 month period. |
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FINANCIAL INFORMATION |
Banks Loss Payable |
Indicate the total banks loss payable or the most recent 12 month period. |
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LIQUOR LIABILITY |
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Complete this section if liquor liability coverage is to be provided. Use the Remarks section if more space is needed to provide responses. |
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LIQUOR LIABILITY |
Liquor License Number |
Provide the liquor license number. |
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LIQUOR LIABILITY |
Liquor License Type |
Indicate the type of liquor license. |
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LIQUOR LIABILITY |
Number of Bars on Premises |
Indicate the number of bars on the premises. |
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LIQUOR LIABILITY |
Number of Bartenders |
Indicate the number of bartenders on the premises. |
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LIQUOR LIABILITY |
Number of Waiters/Waitresses |
Indicate the number of waiters and/or waitresses on the premises. |
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LIQUOR LIABILITY |
Average Length of Employment |
Indicate the average length of employment. |
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LIQUOR LIABILITY |
Check all that apply |
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LIQUOR LIABILITY |
Beer Sales |
Check this box if beer is sold. |
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LIQUOR LIABILITY |
Wine Sales |
Check this box if wine is sold. |
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LIQUOR LIABILITY |
Full Bar |
Check this box if there is a full bar (beer, wine, liquor). |
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LIQUOR LIABILITY |
Written Policy on Serving Alcohol for Employees and Customers |
Check this box if there is a written policy on serving alcohol for employees and customers. |
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LIQUOR LIABILITY |
Management Notified Prior to Shutting Off Patrons |
Check this box if the management is notified prior to shutting off patrons. |
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LIQUOR LIABILITY |
Steady Bar Clientele |
Check this box if there is a steady bar clientele. |
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LIQUOR LIABILITY |
Shots Given/Served |
Check this box if shots are given or served to customers. |
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LIQUOR LIABILITY |
Shots Specials |
Check this box if there are shot specials provided. |
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LIQUOR LIABILITY |
Reduced Price Drinks |
Check this box if reduced price drinks are offered. |
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LIQUOR LIABILITY |
Happy Hour |
Check this box if there is a happy hour. |
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LIQUOR LIABILITY |
Last Call Given |
Check this box if a last call is given. |
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LIQUOR LIABILITY |
Time |
If a last call is given, indicate the time of the last call. |
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LIQUOR LIABILITY |
Sales of Package Goods |
Check this box if packaged goods are sold. |
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LIQUOR LIABILITY |
Percent of Liquor Receipts |
If packaged goods are sold, what is the percent of total liquor receipts |
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LIQUOR LIABILITY |
Explain all "YES" responses unless stated otherwise |
Enter Y for a "YES" response. Enter N for a "NO" response. |
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LIQUOR LIABILITY |
1. Are employees given liquor training? |
If "YES", explain type and when trained. |
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LIQUOR LIABILITY |
2. Have there been any board violations? |
If "YES", list all violations and dates of violations. |
ACORD 185 (2007/05) 7 of 8
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Section Name |
Field Name |
Field and/or Section Description |
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3. Is documentation kept on each |
Indicate by Y for a "YES" response or N for a "NO" response, if documentation is kept on |
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LIQUOR LIABILITY |
incident shutting off patrons? |
each incident of shutting off patrons. |
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ENTERTAINMENT |
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INFORMATION |
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Complete this section if entertainment is provided on premises. |
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ENTERTAINMENT |
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INFORMATION |
Type of Entertainment |
Check all types applicable. If "Other", describe. |
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ENTERTAINMENT |
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INFORMATION |
Nights of Week |
Check the nights of the week in which entertainment is provided. |
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ENTERTAINMENT |
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INFORMATION |
Age of Clientele |
Check the applicable age bracket(s). |
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ENTERTAINMENT |
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INFORMATION |
Dancing Permitted |
Check this box if dancing is permitted. |
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ENTERTAINMENT |
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INFORMATION |
Dance Floor |
Check this box if there is a dance floor on the premises. |
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ENTERTAINMENT |
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INFORMATION |
Amusement Devices |
Check the applicable box(es). Blank space is provided for options not previously defined. |
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ENTERTAINMENT |
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INFORMATION |
Count |
Indicate the number of each amusement device. |
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ENTERTAINMENT |
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INFORMATION |
Description |
Provide a description of each amusement device. |
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ENTERTAINMENT |
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INFORMATION |
Explain all "YES" responses |
Enter Y for a "YES" response. Enter N for a "NO" response. |
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ENTERTAINMENT |
1. Are there bouncers or |
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INFORMATION |
doormen? |
If "YES", indicate why. |
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BED & BREAKFAST |
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INFORMATION ONLY |
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Complete this section if the risk is a bed & breakfast inn. |
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BED & BREAKFAST |
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INFORMATION ONLY |
Name of Inn |
Provide the name of the inn. |
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BED & BREAKFAST |
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INFORMATION ONLY |
Number of Guest Rooms |
Indicate the number of guest rooms. |
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BED & BREAKFAST |
Cleaning Solvents Storage |
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INFORMATION ONLY |
Location |
Indicate where the cleaning solvents are stored. |
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BED & BREAKFAST |
Cleaning Solvent Cabinet Locked |
Check this box if the cleaning solvent cabinet is locked and/or the cleaning solvents are |
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INFORMATION ONLY |
or Stored out of Reach of Children. |
stored out of reach of children. |
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Section Name |
Field Name |
Field and/or Section Description |
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BED & BREAKFAST |
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INFORMATION ONLY |
Explain all "YES" responses |
Enter Y for a "YES" response. Enter N for a "NO" response. |
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1. Does the owner reside |
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BED & BREAKFAST INFORMATION ONLY |
elsewhere; or is the inn operated by someone other than the owner? |
If "YES", provide the name and the experience of the operator. |
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BED & BREAKFAST INFORMATION ONLY |
2. Does inn provide guests with any sports equipment, including boats, bicycles, motorcycles or horses? |
If "YES", describe. |
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REMARKS |
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Use this section to provide any additional information required for underwriting or rating. |
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Check any items which are attached to the application. If not previously defined, indicate |
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ATTACHMENTS |
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in the space provided. |
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SIGNATURES |
Applicant/Named Insured Name |
Print the name of the applicant or named insured. |
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Applicant/Named Insured |
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SIGNATURES |
Signature |
The applicant or named insured must sign the application. |
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SIGNATURES |
Date |
Date the application was signed. (MM/DD/YYYY) |
ACORD 185 (2007/05) 8 of 8
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