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WPMF 02 01 13-FL
Page 1 of 4
WPMF 02 01 13-FL
(Supplement to General Liability Application)
Applicant Name:
Street Address
1. Type of business: Family Style Fast Food
Diner Buffet Fine Dining Take-Out
Microbrewery Other: ________________________
Note: Sports Bars, Nightclubs, Bottle Clubs, Gentlemen Clubs and other private clubs are
not eligible.
2. Valet Parking? Yes No
3. Surface of parking lot (concrete, asphalt, gravel, dirt, etc.)
4. Clientele: Local Residents Families
College Business Tourists
Transient Other
5. Age range of most customers: ______ to ______
6. Seating Capacity: ______
7. Type of foods served: ______________________________
8. Raw meats served? Sushi Oysters Steak Tartare
9. Any tableside cooking: Yes No
10. Any off-premises catering done? Yes No
11. Any delivery done? Yes No
12. Describe any other off-premises operation:
13. Is business located within another business facility (i.e., an airport, bowling
center, skating rink, retail store, etc.)? Yes No If yes, describe
14. Is premises on any dock, pier, or beach?
Yes No
15. Does insured promote any of the following events?
Happy Hour Ladies Night Wet T-Shirt Night
16. Does insured have any of the following? Bouncers
Security Guards Doormen/ID Checkers
17. Describe any live entertainment provided: _____________
18. Is dancing permitted? Yes No
19. How many amusement devices are there?
______Pool/Billiard/Snooker Tables ______Dart Boards
______Children’s rides of any kind ______Movie Screens
______Playrooms or playgrounds ______Mechanical Bulls
______Video Game Machines ______Stage Plays
______Gambling Machines ______Volley Ball Courts
______ Other Types of Machines (Describe.) _____________
20. Are customers permitted to actively participate in any form of entertainment? (If
‘yes’, explain.) Yes No
24. Are all cooking surfaces and deep fryers under an
approved metal exhaust hood? Yes No
25. Is there a written contract for commercial cleaning of the
exhaust hood including ductwork and filters at least every 6
months? Yes No
26. Are all cooking surfaces and deep fryers protected by an
automatic extinguishing system meeting UL300
requirements? Yes No
27. Is there a written maintenance contract for servicing the
automatic extinguishing system least every 6 months?
Yes No
28. Are exhaust filters cleaned or replaced least weekly?
Yes No
29. Are there automatic gas or electric fuel shut-offs for the
cooking appliances? Yes
30. Can the fuel shut-offs be manually pulled? Yes No
31. Are there portable type K fire extinguishers mounted on the
kitchen wall in easily accessible places? Yes No
32. Do deep fryers have high temperature cut-offs?
Yes No
33. Are grease drip pans/trays emptied daily? Yes No
34. Is there at least 18 inches between hoods, ducts, cooking
equipment and combustible materials? Yes No
35. Is cooking done on: Open pits/hearths Open flame
36. Years in business? _______This location
37. Currently open for business? Yes No
If no, when is opening anticipated?
38. Hours of operation:
39. Days of week open for business:
40. Seasonal? Yes No Dates
41. Is this a franchise operation? Yes No
42. No. of years experience? Owner ______ Manager
43. Has owner/manager ever been involved in:
foreclosure bankruptcy business failure (Explain on
back side of page.)
44. No. of employees: ______Full Time ______ Part
45. Any habitational occupancy? Yes No
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