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Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits annapplication form is recognized to be the basis of any policy of insurance, which may be issued by the insurer.}The completion of this application does NOT bind the insurer to offer coverage, and the misstatements of facts may avoid yourdapplication or files a claim containing a false or deceptive statement is guilty of insurance fraud.Broker's SignatureAIRSA (2/2009)DBACityStreet AddressZipType of RestaurantCAIs this a franchise? Customer AreaYears at this locationAPPLICANT INFORMATION!Liquor (Alcoholic Beverage) SalesGENERAL LIABILITY SECTIONOpen 24 hours?Catering Operation?Is Liquor Liability Desired?:Any disciplinary action(s) by the ABC in the past 5 years?PROPERTY SECTIONConstruction TypeTotal Occupied AreaOriginal Year BuiltBusiness Personal Property(Is the entire building 100% sprinklered??Is the premise equipped with active Central Station FIRE Alarm?BIs the premise equipped with active Central Station BURGLAR Alarm?,Building (or Tenants I & B) Limit (OPTIONAL)Table Service?ZipTerr Multiplier   $Unattached / Outside Sign (OPTIONAL)0Equipment Breakdown Coverage Desired? (OPTIONAL)Restaurant Class First 500Per 100RateMin PremABCDMedical Payments RatesLimitCateringLimits DeductibleFactorProperty DeductibleFrameBrickMasonryJoisted MasonrySteelConstruction ClassProp Rates PC1-5 ConstructionRateFire Resistive/How would you rate the condition of the premise Food SalesAnnual Gross SalesYESNONOT APPLICABLEFRAMEBRICKJOISTED MASONRYNON-COMBUSTABLEFIRE RESISTIVESTEEL>Delete Personal and Advertising Injury Liability (5% credit)? Each Occurrence AggregateMed PayProducts/Completed Ops Fire LegalPersonal/Advertising InjuryLiquor LiabilityGeneral Liability Rating Base RateExposure TerritoryScheduled Credit / Debit Program Mod Final RateTotalFirst 500 Sq. Ft.Each Additional 100 Sq. Ft.Medical Payments 5% CreditLiquor Liability RatingScheduled FactorMOD Liquor SalesMinimum PremiumProperty RatingProp DeductibleSubject Val/CoinsAmountTerritory FactorDeductible Factor Final ratePremium BPP - Loc. 1Business Income w/ EEUnattached Sign (Outside) Class CodeExposure / ValuePREMIUM SUMMARYOptional TRIA Charge Policy FeeCREDIT AND DEBIT DOCUMENTATION"Liquor Liability Rating Deviations+ OR -AOR no losses with Acceptance within the last 2 consecutive years. 10% Credit5% Debit6Any disciplinary action by the ABC in the last 5 years Liquor Total#General Liability Rating DeviationsMLoss Free: Applicable if no losses with any carrier within the last 5 years. GL TotalProperty Rating DeviationsCentral Station Burglar AlarmCentral Station Fire Alarm Prop Total/If less than 3 years, total years of experienceYesSq. Ft.State &If yes, % of Catering from Gross Sales <Any Entertainment (Other than solo background music player)? GL Ded (PD): Any claims?+If Yes, stop serving liquor before 11:30PM?(* PoorAverageGood Very GoodProperty Deductible DesiredPROPERTY COVERAGE SECTIONFIs the applicant willing to cooperate with any safety recommendations?Any Banquet Halls?-If so, size of the hall/room being rented outNoNon Franchised fast food or refreshment stands; no table service; liquor sales not greater than 20% of total gross receipts; no square footage limitation. May include individual franchise owners but not stores owned by the franchisor.Class DescriptionCondition of PremiseLiquor Liability $1,000,000ClassRateMin PremABCNon-CombustableALSg OR 7 years (7% credit) OR Applicable to risks in business at least 3 years (5% credit)5 to 10% CreditReason: Rating Class PeculiaritiesInspection Fee Not CoveredBI w/ EE will excluded?ALS Not available on risks with annual sales exceeding $500,000Table service; liquor sales less than 30% of total gross receipts; public area limited to 2,500 sq. ft.; minor entertainment (video games, karaoke, or music apply 10% debit); no live music; no dancing; no valet or garage keepers exposure.^Table service; liquor sales less than 40% of total gross receipts; public area limited to 4,000 sq. ft.; minor entertainment (video games, karaoke, or background music but no live music other than a single performer); no dancing. Valet parking must be covered elsewhere and Additional Insured certificate provided with an insurer rated "B" or better. Any Delivery?TOTAL POLICY PREMIUM?ALS not available. Enter the desired Business Income limit hereDATE: APPLICANT: CARRIER: "Newly Acquired property (building)"Newly Acquired Property (contents)Computers (not EDP Form) Extra ExpenseExcluding Terrorism CoverageIncluding Terrorism Coverage Broker FeeaIf an inspection fee is shown in the premium summary, coverage is subject to favorable inspectionYNuclear Energy Liability Exclusion Endorsement (Broad Form); Expected or Intended Injury;^Contractual Liability; Workers' Compensation and Similar Laws Exclusion; Employer's Liability;2Employment Related Practice; Abuse or Molestation.KLimitation of Coverage to Designated Premises-Project and/or ClassificationExclusion-Voluntary Labor)Pre-Existing Injury or Damage EndorsementDProtective Safeguards (Auto Ansul System covering all cooking areas)?If you wish to bind, please forward the following to our office|any conflict between the coverage statements within this proposal and the actual policy, the policy provisions will prevail.KI hereby elect to purchase Terrorism coverage for a prospective premium of .^I hereby decline to purchase terrorism coverage. I understand that I will have no coverage for'losses resulting from acts of terrorism"Policyholder/Applicant's Signature% Insurance Company Print Name' Policy NumberDate TRIA 01 08Quotation is valid for 30 daysGENERAL LIABILITY SECTIONGeneral AggregateProducts/Completed OperationsPersonal/Advertising InjuryEach OccurrenceFire Legal LiabilityMedical Payments Causes of Loss: SubjectLimitValuation / CoinsuranceEXTENDED PROPERTY BENEFITSAccounts Receivabledeductible of $1,000.#Demolition and ICC (combined limit) Applicant:PNo flat cancellation. Premium is minimum and deposit. All fees are fully earned.DBA: :Acceptance Indemnity Insurance Co. (CA Admitted; A- Rated)"Per Claim / Including Defense Cost Property Damage Deductible: $500Building or Tenants I & B#The following benefits are INCLUDEDAll coverages assume a minimum(in the policy with no additional charge.DBA:aTotal Pollution; Aircraft, Auto or Watercraft; War or Military Actions, or Terrorism; Asbestos orZLead; Silica or Silica Related Dust; Communicable Disease(s); Subsidence; Fungus or Spore;^of Attorneys' Fees; Infringement of Copyright, Patent, Trademark or Trade Secret; Cross Suits;YChromated Copper Arsenate Treated Wood; Punitive, Exemplary Treble Damages or Multipliers)EXCLUSIONS: Including but not limited to: 3TERMS AND CONDITIONS: Including but not limited to:Exclusion-Firearms and Weapons?Please fully cooperate with the independent inspection company.Policy PremiumTOTALFire Department Service Charge Food Spoilage  Equip. BreakdownInventory and Appraisals!Money and Securities (In and Out)Property of OthersOutdoor Property Personal BelongingsProperty In TransitSewer Back Up (Contingent only)Temporary LocationValuable Records  PREMIUM SUMMARYBINDING INSTRUCTION:)1. Application fully completed and signedh2. Restaurant supplemental (AND Liquor Application if liquor has been quoted) fully completed and signed< K3. Terrorism Disclosure (TRIA) Form completed (Accept or Reject) and signedT4. Full annual premium or downpayment (Please consult your agent/broker for details)kThis is a premium indication only based upon information provided by you. The coverage descriptions in thisPOLICYHOLDER DISCLOSURENOTICE OF TERRORISMINSURANCE COVERAGEn You are hereby notified that under the Terrorism Risk Insurance Act, as amended, that you have a rightp to purchase insurance coverage for losses resulting from acts of terrorism, as defined in Section 102(1)s of the Act: The term  act of terrorism means any act that is certified by the Secretary of the Treasury inn concurrence with the Secretary of State, and the Attorney General of the United States to be an act ofv terrorism; to be a violent act or an act that is dangerous to human life, property, or infrastructure; to haves resulted in damage within the United States, or outside the United States in the case of an air carrier or i vessel or the premises of a United States mission; and to have been committed by an individual ors individuals as part of an effort to coerce the civilian population of the United States or to influence theQ policy or affect the conduct of the United States Government by coercion.Q YOU SHOULD KNOW THAT WHERE COVERAGE IS PROVIDED BY THIS POLICY FOR LOSSESO RESULTING FROM CERTIFIED ACTS OF TERRORISM SUCH LOSSES MAY BE PARTIALLYQ REIMBURSED BY THE UNITED STATES GOVERNMENT UNDER A FORMULA ESTABLISHED BYR FEDERAL LAW. HOWEVER, YOUR POLICY MAY CONTAIN OTHER EXCLUSIONS WHICH MIGHTQ AFFECT YOUR COVERAGE, SUCH AS AN EXCLUSION FOR NUCLEAR EVENTS. UNDER THISK FORMULA, THE UNITED STATES GOVERNMENT GENERALLY PAYS 85% OF COVEREDU TERRORISM LOSSES EXCEEDING THE STATUTORILY ESTABLISHED DEDUCTIBLE PAID BY THEN INSURANCE COMPANY PROVIDING THE COVERAGE. THE PREMIUM CHARGED FOR THISS COVERAGE IS PROVIDED BELOW AND DOES NOT INCLUDE ANY CHARGES FOR THE PORTION@ OF LOSS COVERED BY THE FEDERAL GOVERNMENT UNDER THE ACT.P YOU SHOULD ALSO KNOW THAT THE TERRORISM RISK INSURANACE ACT, AS AMENDED,X CONTAINS A $100 BILLION CAP THAT LIMITS U.S. GOVERNMENT REIMBURSEMENT AS WELL ASV INSURERS LIABILITY FOR LOSSES RESULTING FROM CERTIFIED ACTS OF TERRORISM WHENW THE AMOUNT OF SUCH LOSSES IN ANY ONE CALENDAR YEAR EXCEEDS $100 BILLION. IF THET AGGREGATE INSURED LOSSES FOR ALL INSURERS EXCEED $100 BILLION, YOUR COVERAGE MAY BE REDUCED.? Acceptance or Rejection of Terrorism Insurance Coverage"Acceptance Indemnity Insurance Co.TBD COMMENTS:&RESTAURANT PACKAGE INSURANCE QUOTATIONproposal are abbreviated. You will need to refer to the policy for all terms, conditions, limitations, and exclusions. If there isProperty Deductible:Small Restaurant Supplemental Producer:<Complete in addition to ACORD Application (125, 126 and 140)Insured: Location:Total Restaurant Area:Sq. ft.Customer Area: Food Sales:$ Liquor Sales:1Number of years in business at the same location:Yrs.Years of Experience:1a1b2a2b# of Employees: BartendersServers Cook/ChefSecurity/ID CheckersThe deep fat fryers are:GasElectricNo deep fat fryers/Is there an automatic checmical (ansul) system?If Yes,orWETDRY8aJDoes the applicant have flue cleaning service for hoods, filers and ducts?8bIf yes, what is the frequency? Quarterly Semi-AnnualAnnualOtherType of electrical wiring:CopperAluminum9a9b Type of Roof:If yes, explainSingle occupancy building?If no, list other occupants:12a Days Open:Hours of Operation:12b When can we inspect the premise?13aCIs the restaurant in the course of construction or being remodeled?13b(If yes, for how long and to what extent? Any Catering?If yes, percentage of catering:Applicant's Agreement}1. I warrant that all of the information provided by me is true and correct. I also understand that if any of the informationyprovided in this application is not true, then any and all insurance coverage will be void from the effective date of the#insurance coverage and/or canceled.y3. My signature below authorizes any and all of my prior insurance companies to release any and all of my prior insurance<and claims information to RIC Insurance General Agency, Inc.Applicant's SignatureDate: Print Name:Title:Broker's Agreement|1. I understand that incomplete and / or unsigned applications will be refused for binding and no coverage will be in force.{2. I understand that coverage is not bound until such time as I receive written confirmation of binding and a policy number'from RIC Insurance General Agency, Inc.License # 0482919Broker's Signature:Any Banquet Halls rented out? If yes, area being rented out:T2. I have read and understand this entire application. I read and understand EnglishM*Applicant's Signature:%If NEW venture, please complete below@Do you have managerial or ownership experience in this business?1If yes, name of the restaurant (or business name)Address of the restaurantPosition & Duty How Long?%First and Last Name of the Applicant:AIRLLA (2/2009)-Small Restaurant Liquor Liability ApplicationhIf liquor liability is offered, the limits are included within the General Liability limits. See CG 2408Indicate type of area located:Commercial (Non-industrial)Downtown Industrial ResidentialResortRuralSuburban!Do you have any of the following?Athletic Contests or Events Comedy Shows Dance Floor Dart Boards Disc JockeyExotic Dancers Live MusicMechanical Rides Pool Tables Card GamesMovies or Videos Video Games Nude DancersSecurity Guards (Employees)If so, How Many?Security Guards (Independent)Firearms(Guns)Doorman/ID Checkers_If security guards are independent, do they carry liability insurance and provide certificates?2ciIf you X'd any of the above (2a), explain in details (be specific about the type of music provided etc.):/Do you sponsor or provide any of the following?Double for single priceFree Alcoholic Beverages Ladies NightHappy Hour (Drink Specials)Contest (Karaoke or dancing) Predominate age range of patronsUnder 2121-2526-35Over 35lHave you or this establishment ever been charged, cited or fined by the ABC commission or other governmental regulators?If yes, explain:]Have you or this establishment ever has its alcoholic beverage license suspended or revoked? 9Have all servers of alcoholic beverages properly trained?@Are all newly employed servers trained within 60 days of hiring?tDo you provide written policies and procedures to your employees regarding not serving alcoholic beverages to minorsand intoxicated persons?6Do you provide FREE rides home to intoxicated patrons? If yes, how?mDo you have any knowledge of any injury or accident, which might have been caused by the serving of alcoholicof this application?pbeverages from your establishment, which occurred after the requested effective date and prior to the completionUIf yes, explain in details including name of injured party(ies) and date of incident:~I declare that the above statements and particulars are true and that no facts have been suppressed or misstated and that this"RIC Insurance General Agency, Inc.YPlease read the terms carefully as they may differ from requested terms, limits, coverageXand conditions. Forms applicable are subject in all aspects to the terms, conditions andWlimitations of the policy or cover notes in current use by the insurer unless other< wise=specified. No binding authority is conveyed to any producer.KPlease review the attached and submit the following on or prior to binding.CPlease do not hesitate to contact us should you have any questions.GENERAL LIABILITY SECTIONGeneral AggregateProducts/Completed Operations DeductiblePer Claim / PDPersonal/Advertising InjuryEach OccurrenceFire Legal LiabilityMedical Payments  Causes of Loss: Deductible: Per OccurrenceSubjectLimitValuation / CoinsuranceEXTENDED PROPERTY BENEFITS/The following Additional Benefits are included &in the policy. All coverages assume a Accounts Receivabledeductible of $1,000. #Demolition and ICC (combined limit)ISO Class Code Program Class2ADDITIONAL INSURED ENDORSEMENT AND SPECIAL WORDING A. Landlord - No charged B. All Others - Submit to Company for approval (10% of Liability Premium subject to $100 Minimum)Premium Excluding TRIA Base PremiumTotal Policy Premium COMMISSION : SPlease ask your insured to fully cooperate with the independent inspection company.IMPORTANT ADDITIONAL NOTES-* Incomplete submission will NOT be processed* Backdating is not allowed7* Be sure to fully complete the application to include:- 1. Inspection contact name and phone numberO 2. Number of years insured has been in business & prior insurance information( 3. Correct limits and values as quotede 4. Complete information on property(ies) such as year built, updates, area, adjacent exposures etc.~This is a premium indication only based upon information provided at the time of submission. The coverage descriptions in thisproposal are abbreviated. You will need to refer to the policy(ie) for all terms, conditions, limitations, and exclusions. If there isMANDATORY ENDORSEMENTSForm # DescriptionForm #CLP- J1&Common Policy Conditions/Policy JacketCLP-J1 Policy JacketJDL 19000 11-85Common Policy Declaration PageJDL 190&Comm. Property Cvrg Part- Declarations TRIA 0106+Policyholder Disclosure Notice of TerrorismAP 3000Property Cvg. Amendatoroy Endt.IL 4018Forms Schedule ListAP 3150 Amendatory Endt.- Causes of Loss JDL 190(2)"General Liability Declaration PageCP 0010&Bldg & Personal Property Coverage Form CG 0001 1001CG Coverage Form OccurrenceCP 0090Commercial Property ConditionsIL 0003Calculation of PremiumCP 1010Causes of Loss - Basic FormCG 0300Deductible EndorsementCP 1020Causes of Loss - Broad FormAL 1444CP 1030Causes of Loss- Special FormAL 1452 Exclusion-Assault and/or BatteryCP 1033Theft ExclusionCG 2146Abuse or Molestation Exclusion CP 1056Sprinkler Leakage ExclusionCG 2147!Employ-Related Practice ExclusionIL 0415Protective SafeguardsCG 2149Total Pollution ExclusionCP 1211Burglary and Robbery ProtectionCG 2169War or Terrorism ExclusionCP 1218Loss Payable ProvisionsCG 2175(Exclusion of Certified Acts of TerrorismCP 1440 Outside SignsCG 2177 Exception to Terrorism ExclusionCP 1531Ordinance or Law-IncreasedCG 2404Waiver of Transfer RightsCP 0030$Business Income and/or Extra ExpenseCG 2407 Prod/Completed Operations HazardCG 2408IL 0270#CA- Change Cancellation/Non RenewalCG 2002!Additional Insured - Club MembersIL 0938!Exclusion of War, Military ActionCG 2011&Additional Insured-Managers or LessorsAL 1513#Equipment Breakdown Coverage End't.CG 2012,Additional Insured-State Pol-Sub Div-PermitsCG 2015Additional Insured - VendorsCG 2026.Additional Insured - Designated Person or Org. AL 1488Exclusion - Water Damage            r You are hereby notified that under the Terrorism Risk Insurance Act, as amended, that you have a rightt to purchase insurance coverage for losses resulting from acts of terrorism, as defined in Section 102(1)w of the Act: The term  act of terrorism means any act that is certified by the Secretary of the Treasury inr concurrence with the Secretary of State, and the Attorney General of the United States to be an act ofz terrorism; to be a violent act or an act that is dangerous to human life, property, or infrastructure; to havew resulted in damage within the United States, or outside the United States in the case of an air carrier or m vessel or the premises of a United States mission; and to have been committed by an individual orw individuals as part of an effort to coerce the civilian population of the United States or to influence theU policy or affect the conduct of the United States Government by coercion.U YOU SHOULD KNOW THAT WHERE COVERAGE IS PROVIDED BY THIS POLICY FOR LOSSESS RESULTING FROM CERTIFIED ACTS OF TERRORISM SUCH LOSSES MAY BE PARTIALLYU REIMBURSED BY THE UNITED STATES GOVERNMENT UNDER A FORMULA ESTABLISHED BYV FEDERAL LAW. HOWEVER, YOUR POLICY MAY CONTAIN OTHER EXCLUSIONS WHICH MIGHTU AFFECT YOUR COVERAGE, SUCH AS AN EXCLUSION FOR NUCLEAR EVENTS. UNDER THISO FORMULA, THE UNITED STATES GOVERNMENT GENERALLY PAYS 85% OF COVEREDY TERRORISM LOSSES EXCEEDING THE STATUTORILY ESTABLISHED DEDUCTIBLE PAID BY THER INSURANCE COMPANY PROVIDING THE COVERAGE. THE PREMIUM CHARGED FOR THISW COVERAGE IS PROVIDED BELOW AND DOES NOT INCLUDE ANY CHARGES FOR THE PORTIOND OF LOSS COVERED BY THE FEDERAL GOVERNMENT UNDER THE ACT.T YOU SHOULD ALSO KNOW THAT THE TERRORISM RISK INSURANACE ACT, AS AMENDED,\ CONTAINS A $100 BILLION CAP THAT LIMITS U.S. GOVERNMENT REIMBURSEMENT AS WELL ASZ INSURERS LIABILITY FOR LOSSES RESULTING FROM CERTIFIED ACTS OF TERRORISM WHEN[ THE AMOUNT OF SUCH LOSSES IN ANY ONE CALENDAR YEAR EXCEEDS $100 BILLION. IF THEX AGGREGATE INSURED LOSSES FOR ALL INSURERS EXCEED $100 BILLION, YOUR COVERAGE MAY BE REDUCED.C Acceptance or Rejection of Terrorism Insurance CoverageProducerX0REQUIRED TO BIND - FAX or E-MAIL checked items3.The above-mentioned policy is set to expire on&Acceptance Indemnity Insurance CompanyIncl. Defense CostBuiding or TIB - Loc. 1 Other Fees%Special Exclusion & Limitation End't. TRIA 01 08Kindest Regards,/"Save our trees and office expense by emailing"<Thank you for allowing us to quote the above-mentioned risk.AP 3036 (0808)%Business Income Actual Loss Sustained Named InsuredNOAQNOTE: The renewal reflects the most current information per inspection as follows"Stated Amount on 1/4 Monthly Limit-Business Income with Extra Expense (OPTIONAL)Business Income on ALSMLoss Free: Applicable if no losses with any carrier within the last 5 years. WRenewal: Applicable to risks written with Acceptance for TWO(2) consecutive prior yearsLEarly Closing: Applicable to risks that stop serving alcohol before 11:30 PM<New Business / New Venture (Must have verifiable experience)bYears in Business at Same Location: Applicable to risks in business at least 10 years (10% credit)#+Sprinkler Credit (only if 100% Sprinklered)Min Prem (if any) GL Class CodeProperty Class CodeGeneral Liability LimitsMisc. GL Endorsement Rating OFFICE USEA/I = LandlordA/I = State, City A/I - Vendors A/I = Others Loss PayeeWaiverTRIA Accepted? End't PremiumPrem / Prod Total,General Liability - Premises/Products RatingTotal Endorsement PremiumTIB or Building - Loc.1e C. Special Wording - Submit to Company for approval and pricing. Primary <wording is NOT available. Business Income w/ Extra Expense6Liquor Liability Endorsement Class Code: 58161%?POLICY PREMIUM SUMMARYbYears in Business at Same Location: Applicable to risks in business at least 10 years (10% credit)$RNumber of Additional Insured Other than Landlord *If landlord only, enter 0 . 0 2BOPTOTAL GENERAL LIABILITYTOTAL PROPERTY Other FeeG Forms made part of the policy at time of issue as designated by "X"ECauses of Loss * EQUIPMENT BREAKDOWNTOTAL INSURABLE VALUE (TIV) Basis%GENERAL LIABILITY SCHEDULE OF HAZARDSCustomer Area 0Additional Insured - Other than Landlord?Construction Type (Loc. 1) Commission: # of Inspection RequiredGross DownpaymentPremium Including TRIA : Renewal ofQuoting Office4CA Small Restaurant Premium Rater (Version 052009)!K#NWC Insurance Services"Louis T. Mastos & Associates, Inc.$P.O. Box 2406, Tustin, CA 92781-2406#P.O. Box 1180, Santa Rosa CA 95402 License # 05805811Delete Peronal and Advertising Injury (5% credit)&*General Liability Program Mod Explanations GL MOD TotalOther:&OLD (Pre 12/1/2009) - Some self-ratersDate: Producer: Carrier: (CA Admitted; A- Rated) Base Rate Dear Producer:AP 3004Property Coverage EnhancementInsuredCompanyPolicy #jAn inspection of the above-mentioned insured has been completed and the following safety recommendation(s)need your immediate attention:mPlease forward proof of compliance (This letter completed and signed by insured with photos and/or receipts) ,within thirty (30) days OR prior to renewal.mIf unable to comply with any recommendation within thirty days, please provide a written response within ten k(10) days of the intent to comply with the suggestions and the length of time anticipated needed to comply.?Should you have any questions, please contact your underwriter.Underwriting DepartmentaPlease allow until ____/____/____ to fully comply with the above recommendation(s). We understand Exp. Date]that failure to comply with above recommendation(s) in timely manner will constitute material2cancellation of our policy and denial of coverage._____/_____/_____Date Completed / Complied:aWe have complied with above recommendation(s). We understand any misrepresentation will result in2__________________________________________________________________ Insured's Signature Date Signedimisrepresentation and/or non-compliance and will result in cancellation of policy and denial of coverage.#CALIFORNIA Small Restaurant ProgramEligibility Questions+Are you quoting more than one (1) location?Any amusement devices?WAny policy (previous or current) canceled, declined or non-renewed in the last 3 years?Any past losses or claims?AAny entertainment? (example: Dancing, Contests, DJ's, Live Bands)WAny commercial cooking and/or deep fat fryers (other than microwave and warming ovens)?4Any previous ABC violations within the past 5 years?AAny security guards or bouncers employed by the restaurant owner?*Any locations outside of the domain state?WIs the customer area (total area minus kitchen and storage) greater than 4,000 sq. ft.?RLiquor (including beer and wine) sales exceed 40% of the total annual gross sales?2Serve liquor (including beer and wine) after 2 AM?<Is the premise equipped with automatic extinguishing system?"more than $1,000,000 per location?SDoes the TIV (Building + Business Personal Property + Business Income) limit exceedELIGIBILITY STATUS(Name of the person completing this form:Code Ref. CodeFTerrorism (TRIA) form completed and signed by the insured (See page 5)]Completed and signed Small Restaurant Supplemental (See Supplemental Application TAB, page 1)RCompleted and signed Liquor Application (See Supplemental Application TAB, page 2)+Toll Free: 888.693.7892 * Fax: 866.577.7595#A Division of RIC Insurance GeneralCopy of your agency trust check%Copy of the premium finance agreement.Complete only if Liquor Liability is requestedNWC Insurance Services *A Division of RIC Insurance General Agency!PO Box 7307, Santa Rosa, CA 95407 f r FL]?ߎs% - |" < v 2 RWK"_ڞŠkNy0=6%'/ q < N #?ҶV3C0)%ӾWWϿSnQEs-M[2x65OH D #  h g 1]} eZ k%%u^DMXP P >z 2ncc||"}-}; 00\);_(*}A}1 00\);_(*;_(@_) }A}2 00\);_(*?;_(@_) }A}3 00\);_(*23;_(@_) }-}4 00\);_(*}A}0 a00\);_(*;_(@_) }A}( 00\);_(*;_(@_) }A}7 e00\);_(*;_(@_) }}5 ??v00\);_(*̙;_(@_)    }}9 ???00\);_(*;_(@_) ??? ??? ??? ???}}) }00\);_(*;_(@_)    }A}6 }00\);_(*;_(@_) }}* 00\);_(*;_(@_) ??? ??? ??? ???}-}= 00\);_(*}x}800\);_(*;_(??? ??? ???}-}/ 00\);_(*}U}< 00\);_(*;_( }A}" 00\);_(*;_(}A} 00\);_(*ef;_(}A} 00\);_(*L;_(}A} 00\);_(*23;_(}A}# 00\);_(*;_(}A} 00\);_(*ef;_(}A} 00\);_(*L;_(}A} 00\);_(*23;_(}A}$ 00\);_(*;_(}A} 00\);_(*ef;_(}A} 00\);_(*L;_(}A} 00\);_(*23;_(}A}% 00\);_(*;_(}A} 00\);_(*ef;_(}A} 00\);_(*L;_(}A} 00\);_(*23;_(}A}& 00\);_(*;_(}A} 00\);_(*ef;_(}A} 00\);_(*L;_(}A}  00\);_(*23;_(}A}' 00\);_(* ;_(}A} 00\);_(*ef ;_(}A} 00\);_(*L ;_(}A}! 00\);_(*23 ;_(-  !%-  !%-  !%8   !%8  !%I A  !%M 20% - Accent1 ef %M" 20% - Accent2 ef %M& 20% - Accent3 ef %M* 20% - Accent4 ef %M. 20% - Accent5 ef %M2 20% - Accent6  ef %M 40% - Accent1 L %M# 40% - Accent2 L湸 %M' 40% - Accent3 L %M+ 40% - Accent4 L %M/ 40% - Accent5 L %M3 40% - Accent6  Lմ %M 60% - Accent1 23 %M$ 60% - Accent2 23ٗ %M( 60% - Accent3 23֚ %M, 60% - Accent4 23 %M0 60% - Accent5 23 %M4 60% - Accent6  23 %AAccent1 O %A!Accent2 PM %A%Accent3 Y %A)Accent4 d %A-Accent5 K %A1Accent6  F %9Bad  % Calculation  }%  Check Cell  %????????? ??? 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Please submit.VLThis risk is ELIGIBLE for quoting. Please proceed with Applicant InformationB=:This risk requires underwriting approval. Please submit.T%<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<=^)Z&]]RRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRR^^) ']'?\ d D%LThis risk is ELIGIBLE for quoting. Please proceed with Applicant Information piPlease note that you do not have binding authority. All quotes are subject to final underwriting approval  B T'<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<=^) (]4(@!*$!A[' BT(>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>^)Z)]RRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRR^ )Z*)bbt^f^]^^$ **F'  ( PH  0(   >@...%'((&'''%%'##'!!'%'%'%'%'%'%'%'%'((%'%'%' %' %'7%%'%%'O:%%''%%'##'!!'%'%'%' LThis risk is ELIGIBLE for quoting. Please proceed with Applicant Information''''''l?''''%%'##'!!'%'%'%'iPlease note that you do not have binding authority. All quotes are subject to final underwriting approval #'%'%'%'%'%' %' %'%'%'%'%'%'%'%' ''ggD&{+{%%'{+{'''   0jc  dMbP?_*+%&?'?(?)?MAdobe PDFS o:LetterPRIV ''''0\KhCDkSMTJAdobe PDF ConverterResolution1200dpiPageSizeLetterPageRegionLeadingEdgeInputSlotOnlyOne0EBDAStandard":??cU} I } }  } } m} I} } I} m } } } } m} } } } I} $} I} I}  } } I} } I} 0@ ,  ;0;,  ;@0 @0 ,  ,; ;,, #.$$$$$$$ m nn o(oooooooooooo isjj66666666     MQ?7DNWC Insurance Services   B f4ggggggghhhhhhhh &""........  k ll &""........  , - &4""............% &""....%~    ~   %%d@ ND ;mBfA !D ;mBfB t uu/0000000  p  qqq~ ? x yyvww z {{{{  |`iD no D  B$ 16901@D yes D  B$ 1690016910"B16910 || x yN l  8$ A[ D ;Bf  B .  & "".. '( ''''''.. &  "".. '( ''''''.. & ""99  '  ''''''99   &"".. 'D(''''''778 &C""77J ''''''' ! 7 D D78rr &''.. '(''''''rr &''. ''''''' rr &OO.^^; %D .A  B   j TDyes !Risk not qualified for NOA"Non Owned Auto LiabilityBNon Owned Auto Liability  rr &''..ypcDYes G@Do not continue rating. Please submit currently valued loss runs  B (rr4DNo HAHow many years of consecutive, (CLEAN) loss runs can you provide?bXDue to claim history, this risk is not eligible for self-rating. Please submit loss runsB[XDue to claim history, this risk is not eligible for self-rating. Please submit loss runs4rr f4ggggggghhhhhhhhrr &'''%% '(''''''%%rr &IIIIIIIIIIII ~  .rr &N4'''''''''%rr &4'''''''%rr &4%rr &4'''''%rr  4rrrrrrrssssssssr &''%%%%%  " ....r)(D  |uDue to age of building, this risk is not eligible for self-rating. Please verify complete building updates and submit  BxuDue to age of building, this risk is not eligible for self-rating. Please verify complete building updates and submit4***************r &4''''''''''%%%%%rDl@VF\\Fr\\~\\r.kF\\FFFFF\c !"#,$%&'()*, +,,-./ &4 ''''''''''%%%%%r !&4!''''''''''%%%%%rr "&B4"''''''''''%%%%%rr # 4#!!!!!!!!!!!!!!!rr $+$(( ~ $ @@$ rr %&%''''''''(( ~ % % rr &&&''''''''(( ~ & & r '&'''''''''(( ' ' r(t D A d@YThis risk does not qualify for Business Income on ALS. Enter desired limit or leave blank  B 4(((r )&&)''''''''(( ~ ) ) r *t'*mmmmmmmm * * }~r&+rrrrrrrrrrrrrrrr&,rrrrrrrrrrrrrrrr&-rrrrrrrrrrrrrrrr&.rrrrrrrrrrrrrrrr&/rrrrrrrrrrrrrrrr$/,FFFF\\\\\\**** r( *r0O(  ~  < XPP?  ]4@4 ԪJ}f'P *<+Doing Business As (Name of the Restaurant)<**;~~  <l XPP?   B]4@l5 >Mix 7<8Description of Operation to include type of food served<f7~~  < XPP? ( PF]4@6 IfOO[) t <If no prior coverage enter 0 (zero) 0 if New or No Prior Coverage 1 if First Year with prior 2 if Second Year with Prior 3 if Third Year with Prior NOTE: Loss runs corresponding with number of years entered are REQUIRED to bind.<  ~~   <4 XPP?  pb]4 @47 U=-EPO q<rIMPORTANT: If loss runs are not submitted at the time of binding, any loss free credits applied will be voided< 1 q~~   < XPP?  ) ]4 @8 ]ʯg{MJP J<KRefer to Restaurant Program Guide Page 2 for details OR Choose from list< Jear Scott Changr Scott Changr  Scott Changr  Scott Changr Scott Changr>@@U'SE@J"+_@<)&?'?(?)?MWinFax oLetterSWFX"`??zo                       **      **   **''  && )) )) ((  %%              (( ## !! && "" '' "" %% $$ !!  $$         7  ?       Risk not qualified for noa l You MUST answer all questions&Pick an answer from the drop down list# G You MUST answer all questionsk #er 3 sw#qu  sw#qu **  !  ! b You MUST answer all questionsPick from the drop down list#+ sw#qu"" + sw#qu$$ v Risk Class Selection Not Valid/Press Delete and choose from the drop down list# + Se# N + Se# N 3 Se# N'' ''+ Se# N+ Se# N Sheet5ggD&rt&U'SE@J"+{+{    Sb2E P  dMbP?_*+%&?'?(?)?MAdobe PDFS o5LetterPRIV ''''0\KhCDkSMTJAdobe PDF ConverterResolution1200dpiPageSizeLetterPageRegionLeadingEdgeInputSlotOnlyOne0EBDAStandard"5??U} I} } } } m}  } I } IS  0     0  @  Y@ @  @ @ @ @ @ @ @ @ @ ] @ @ @ @ @           O~ n.A Pn>A D Q~ n@ ~ p@@  ] R  c Ro.AD S~ oj@ # # # #  ]  Rc _TL` 6Z YES EXCLUDED $1,000,000B $1,000,000 aUJb 4ZYES INCLUDEDEXCLUDEDB EXCLUDED a` "Z 16910 z{  ] R  c  ] R  c   ] R  c V W X Y Z [ \  ]  ]R^ !^M 7: A[ !Z ;BfB7"@@ !Z   B2#? Z;mBf*$? DA{Gz?*$? DF{Gz?- DDDD!&  DA  ]  Rc !_M 7: A[ !Z ;BfB?" )Z  Z B'? D$? D$? D- DDDD1& DD{Gz?A  ]R^ !`1 "* Z ; Bf (@ D e# f# f * D K &* F5$A[ D D -C6*? B _ `d O   9Zyes D - Class Code 44276  B L " 6Z  D ;Bf B> " (Zyes  :  B '? D $? D~ $?'  D D D 1 ) 8D D {Gz?A *++,-  3 m* DDD D A ijjkllhg b   3W 3c 3d 3\ 3e 3f 4P :Zyes Included in GLExcludedB ExcludedV @DINCLUDED  Z ;Bf B*5? D8{Gz?~ ?'5 DDDN 8ZYES Z ZZ BV( @DINCLUDED  Z ;Bf B]. GDD{Gz?D  $DD{Gz?B*++,--%)  Ji Ks KW Kc K K\ Kt L ;$ %D  49950  B 7 !Z  d B<( &Z   $100  B " D Z !F  DDC, -Zyes Catering  B @0 *Zyes  11039  B Q ;Zyes D;Bf B> (Zyes  : B" "DF 0Zyes Z Z  B[& QEDDMbP?D  $DDMbP?BH24 2Zno Non Owned Auto  B V8 @Zno Z .A B$AL 1447  B O 9Zno Z ; Bf B?< )DAL 1447  $  B " D Z!&  DD -. DDDA*++,-w@aD yes GL TRIA Accepted9D no GL TRIA Rejected  "B V @D yes %D DDA{Gz? B] ijj  3Z* !D DDDA]*++--/01 g 78 ZO* 9$A[ D;#Bf B 9b8D LZ YES  Special Form&Special Form Excluding TheftBSpecial Form Excluding Theft: 9h;@@ Z$ 7~ 8@: 9N<* 8$A[ D;',Bf B <<= 2i >j >k ?l ?m ?c >n @o A`B JZ  RC / 90% CoinsuranceACV / 90% CoinsuranceBACV / 90% Coinsurance6 Z% ~ C?MC? 7$A[ D;Bf B*C* DQ{Gz?-C3* DDDD+&* DD{Gz? ApB DACV / 90% Coinsurance6 Z& C? DC? DC* DC3* D+&* DD{Gz?D1lBI@Luc&p1&pGUo&Rp ! " # x@$ % & '  ( 0) 0* ;+ ,, ,- ,. ; / 00012345678 9:;<=>@?@ AqW D AZ(  1/4 Monthly Limit@ Not CoveredB Not Covered Y Z(  C? !D C? D C* D C3* D+ &* D D{Gz? q !Ap!D !ZZ A @Z' ALS @Z(  B$ ALS Not CoveredB Not Covered=!W &'D!ALS  60000 B !CC=!t !'D!ALS  Flat  B U!E "?Z' ALS @Z(  B$ @,@BW!F* *AZ(  @Z  B$@:!@0B "rG"  "1Z)  All RiskEXCLUDEDB EXCLUDED" "Z) "? $D"? !D~ "?;" "%D"  @ B+" D"D"{Gz?#ADXGGGH& $AJ$D  $4Z* YES INCLUDEDEXCLUDEDB INCLUDED?$X $)D$INCLUDED  $& B $GGG@$HX9v? %*Z* YES  X9v? 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B &&7&Y $!DDD D!D"E &III &[&Z* *uDDD D!D"0 D$D%8DDD D!D"@wD$D%B'qrrrrrrs(M )) *vl** &VD DDA{Gz?DDD D!D"D$A?**v8-D No *#Total Policy Premium Excluding TRIA`D Yes *#Total Policy Premium Including TRIATotal Policy Premium"BTotal Policy Premium'*x* .DD&A+u +v~ +x,u ,vw~ ,xY@-u -v?-Y@ 3)Z Zd B.NN .w#.y* dW %*-/OOOOOOOO 0x0 1y1 22 2Rz 3{3 3S|>3T 5(Z   $ B 44 4Sa~ 4T 55 5Sa@5| 6*Z yes   B 66 6S}86|@ 7"Z   B 7~7 7S};7| ;%Z YES  B8 8US8}@ =%379  9%37B 99 :: :Rz ;{; ;S|>;T =(Z   $ B <<S| == =S=| >Z  wZ   SZ   /Z d $@"@""B >> >S}8>~@ ?"Z   B ??JJJJQS@?V @*Z YES   BDlQC7 &22gK&&2r>tlo{&2r&l@@A BCDEF GHIJKLMNOPQ R @P @r@d @\Z YES >7Insured is very cooperative with safety recommendations  B @ @S|@@V C*Z YES  $ BA AUSA@ =%;@ڐ9  9%;@B BBCiC8h CSZ yes 6/Entertainment other than solo background player BC8888:C D$Z yes   BDaD8l DKZ YES -&Delete Personal and Advertising Injury  B D88888:D I$Z yes   BE E8E8F88888 F#F}  %CD GG HH HRz I{I IS|>IT K(Z   $ B JJS| KK KSK| LZ  wZ   SZ   /Z d $@"@""B LL LS|@LT M*Z yes  $ B MM MSa@MT N*Z Yes   B NN NSaANT O+Z! 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PH@0(  >@@U'SE@J"+d@<* &?'?(?)?MWinFax oLetterSWFX"M??j-EE..00))&&QQ>>AAGGHHIIJJKK??BB==8877112233554466 << 99::;;RRLLMMNNOOPP@@7  ? 00))&&QQ> ; #   Sheet4ggD&&U'SE@J"+{+{    <Da&oyzØdc{p  dMbP?_*+%&333333?'?(?)?Mk RICOH Aficio SP C221N PCL 6 (C߀ odXLetter (8.5" x 11")PDudk<Untitled>XH_ Bd222222'''C:\WINDOWS\system32\LA6C\OVERLAY.OVPHc:\ui.prnc:\text.txt ddd."VU} } } I} I } I } I} }  } } } } I } Dh YY Y Y Y @ YYYYY@Y;@YYYYY@YY,,," t ZNWC Insurance Services  v     " " Ŷq@!AJ "  Z "  J  B4: A[ Applicant:  Insured: B Applicant:    Z  J  4: A[ Expiring Policy No.B  ;  %: A[ : B  NNN " "  " " "  II "  z: A[3,We are pleased to offer the following terms.8.The above-mentioned policy is set to expire onB/,We are pleased to offer the following terms.;  %: A[ : B N         "   "  u  t$ D.The above-mentioned policy is set to expire on >7Updated and signed ACORD application (125, 126 and 140)C9Completed and signed ACORD application (125, 126 and 140)B<9Completed and signed ACORD application (125, 126 and 140)  t   t  < &Zyes X  B  D l&l<P&&M&M&&&&&&:&B::::&:&:OFF ,!,",#Y$Y%Y&Y'Y(Y)Y*w@+,,@-Y.Y/Y0w1@2@3@4@5@6@7@8@9@:;h<=>?, 9  #Z  X  B   =Z  +$Currently valued favorable loss runsH>Written verification of ownership and/or management experienceBA>Written verification of ownership and/or management experience  ! !t !! 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