Restaurant Insurance Quote Form

January 14, 2013

Restaurant Insurance Quote Form

As you know, Best Practice is about becoming more efficient, competitive and profitable.  Successful restaurants don’t stand still – they’re always looking for ways to improve management and operations…and to measure the results.

Pacific Insurance Partners has been around your industry long enough to understand the types of tools that help restaurants achieve increased efficiency and avoid loss.  We have developed this Best Practices Assessment tool as part of your loss control program for your restaurant.  Simply, the checklist format points out unsafe activities or conditions and, through that recognition, allows you to correct or remove these activities/conditions before a loss occurs.

But there is additional value.  Pacific Insurance Partners can seek insurance premium discounts based on your Best Practice Efforts and the completion of this assessment form.  Let’s work together on your Best Practice efforts.

Your Name:  *
E-mail: *
Restaurant Name:  *
Location Address:  *
Date: *
 /  / 

General Food and Restaurant Operations: 

Kitchen waste materials stored in metal containers with tight-fitting lids, kept in designated areas and removed by carts to compactor or dumpster?
Are all areas over ranges, grills, fryers, and all other cooking surfaces, hoods and ducts protected by a UL300-compliant automatic fire extinguishing system? If not, describe hood system in Comments.  *
Extinguishing heads capped to prevent a cooking buildup?
Is there emergency lighting?
Extinguishing system's manual pull switches located away from cooking equipment?
Extinguishing system(s) has a semi-annual service contract with qualified firm?
Fuel supply cooking equipment has an automatic shut-off valve when extinguishing system activates?
Deep-fat fryer units controlled and provided with high-temperatures shut-off; overflow gutters provided?
Filters in exhaust system(s) cleaned at least daily?
Exhaust system(s) cleaned at least quarterly by qualified service contractor?
Floors adjacent to deep-fat fryers dry and free of grease?
Floors adjacent to soft-drink syrup (if appropriate) tanks cleaned regularly?
Floors around sink mopped dry?
Knives places in sheaths when not in use?
Proper guards in place and used with meat-slicing machines?

Food Preparation and Handling Practices: 

Perishable or potentially hazardous food properly stored and held at the correct temperature?
Cutting Boards washed and sanitized whenever the use switches between raw food and cooked or ready-to-serve food?
Employees wash hands after wiping tables and busing soiled dishes, before handling place-settings and serving food?

Fire Protection and Prevention: 

Fire Extinguishers

Proper number and type(s) of fire extinguishers, charged and tagged to show last service date?
Fire extinguishers properly wall-mounted, identified and adequately accessible for hazard involved?
Employees trained in proper use of extinguishers and manual operation hood system protecting cooking equipment?
Is there a maintenance agreement to regularly inspect and service the hood system?  *
How many times per year?  *


Is the building protected by a sprinkler system?  *
Sprinkler system control valves secured in open positions?
Minimum of 18 inches clearance between stock storage and sprinkler heads?
Clear space of three feet around sprinkler system's main control valve?
Water pressure indicated on sprinkler system's lower gauge?
Sprinkler system(s) periodically tested and maintained; written records kept on premises?

General Fire Safety

Employees instructed in evacuation procedures for both customers and employees?
Instructions prominently posted for reporting fire and calling Fire Department?
Flammable and combustible liquids (paints, solvents, etc.) stored in metal safety cabinets or off premises?
Storage of combustibles not permitted within 30 feet of boilers, furnaces or other heat sources?

Electrical Equipment: 

All electrical equipment property grounded, portable electrical equipment and extension cords have a ground prong?
Breaker switches properly marked?
Electrical panel boxes have doors closed, clear area of 30 inches in front of boxes?
Switches, switch boxes, outlets and wiring inspected periodically and deficiencies corrected?

Storage Areas: 

Stock properly and securely stacked; stored on racks, shelves or pallets?
Good housekeeping maintained, aisles clear, storage room orderly, floors free of debris, storage has proper clearances from hot-water heater and sprinklers?
Shelves and racks in good repair and secured to avoid tripping?

Cold-storage and Refrigeration Equipment: 

Refrigeration and air-conditioning compressors clean, well ventilated, kept clear of combustibles?
Walk-in cooler and freezer doors provided with operable interior-release mechanisms, alarm system, and axe?
When restocking, new stock placed at rear and old stock moved up front for use first?
Recommended holding times for food followed?

Floors and Walking Surfaces: 

Floor free from food spillage, silverware, broken glassware, loose mats, torn carpets or other hazards?
Portable signs indicate wet-mopped floor or temporary hazards?
Stair treads equipped with abrasive strips or other nonskid surface?
Outdoor walkways checked frequently for tripping hazards; repairs made promptly?
Indoor-outdoor carpeting or other type of mat provided at entrance doors in inclement weather?
Change in interior elevations properly illuminated?


Exits properly marked, illuminated and unobstructed; doors kept unlocked during hours of operation or equipped with panic bars?
Non-exit doors (to rest room area, kitchen, closets, etc.) identified properly?
Secure handrails on all stairs and steps?
Is there emergency lighting?

Exterior Areas: 

Parts and parking lot well illuminated?
Steps, ramps, grounds and parking lot in good repair, free of holes or obstruction, and well illuminated?
Snow and ice promptly removed from parking lot and all walkway surfaces, when necessary?
Car stops (bumper strips) painted contrasting colors so they are clearly visible?


Cash registers emptied and left open during non-operating hours?  *
Cash drawers skimmed frequently to reduce the cash in each drawer?  *
Bank deposits made at least twice daily with varying times and routes?
Combination to safe changed after turnover of money-handling personnel?
Back door equipped with a panic lock so that it can be kept locked at all times, equipped with hinge pins?
Cash register tallies checked against deposits daily; other checks used to detect employee dishonesty?  *
Is there a safe on the premises?  *

General Safe Practices: 

Pest control services performed by a licensed, independent extermination contractor?
Are substances used approved for use in food establishments?
Heimlich Maneuver posters in plain view; employees trained, where required by law?
Fully equipped first-aid kit available at all times; at least one employee on each shift trained in its use?
Certificates of insurance required from all servicing contractors and suppliers?  *
Emergency telephone numbers for police and emergency medical services prominently posted?
Dishes and utensils taken out of service and discarded when chipped, cracked or broken?
What kind of restaurant do you own? Italian, Japanese, American, French, Thai, Chinese, etc.. *
Has applicant had prior insurance?  *
If yes, who?
Radio: *
If yes, please explain:
Has applicant had any losses within the past 5 years?  *
Has applicant been involved in any lawsuits?  *
If yes, explain:
Is the applicant a subsidiary of another?  *
Does the applicant have subsidiaries?  *
Has insured ever been cited by Board of Health? (If yes, please explain in Comments)  *

Accounting Information: 

Please state gross annual receipts for both food and liquor for the following years: 2003, 2004, and 2005: *
Has the owner ever been involved in a bankruptcy or business failure? (If yes, please explain in Comments) *
Number of years in business under current ownership?  *
At this location?  *
Is this business seasonal?  *
Months of Operation:  *
Are audits of applicant done by a CPA or public accountant? *
Is countersigning of checks required?  *
Are bank accounts reconciled by someone not authorized to deposit or withdraw?  *
Are checks stamped immediately "for deposit only"?  *

Facility Information: 

What are the hours of operation?  *
Are minors permitted at all times?  *
Is there a bar or lounge? (If yes, describe in Comments section) *
Is there a Happy Hour?  *
Seating capacity in restaurant:  *
Seating capacity in lounge:  *
Was the building originally built as a restaurant?  *
If no, has wiring, etc., been updated for restaurant occupancy?
 /  / 
Age of building:  *
Square footage of building:  *
Insured on this policy?  *
What is the replacement cost of BPP (tables, chairs, inventory, cooking equipment)?  *
What is the replacement cost of perishables?  *
Are there any buildings of premises owned or occupied by the applicant, but not described on this application?  *
Valet parking?  *
Coat checkroom? *
Are any parking facilities owned or rented?  *
Are any sporting or social events sponsored?  *
Are there any delivery operations?  *
Do off-premises catering receipts exceed 10% of gross annual sales?  *
If yes, what is the %:
Any tableside cooking or food preparations?  *

If liquor is served, describe the training protocol for liquor servers in the Comments. 

Is there live entertainment? (If yes, describe in Comments section) *

Employee Hiring Practices: 

Are references checked prior to employment?
Are there any health department violations at any operation?
Does the applicant have a contract with a professional pest management service for all premises?
Do employees have current Food Handlers Card?
Number of employees:  *
Comments:  *
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