Application for Restaurant Quote

Contact Information
Business Name *
Contact Name *
Contact Phone Number *
Email Address
Do you prefer to be contacted by phone or email? Phone  Email
Mailing Address
Location Address if different from mailing address
General Information
Year business was established
Number of years experience in restaurant industry
Type of business Corporation
Partnership
Sole Proprietor
LLC
Other
Federal Tax ID Number
Is coverage in force now Yes  No
Insurance Company Coverage is with now
Have there been any General Liability losses in the past three years Yes  No
Have there been any Property losses in the past three years Yes  No
Have there been any Liquor Liability losses in the past three years Yes  No
Type(s) of quotes needed (choose all that apply): General Liability
Property
Liquor Liability
Workers Compensation
Commercial Auto
Umbrella
Type of Restaurant Fine Dining With Alcohol
Fine Dining Without Alcohol
Casual or Family Style Dining With Alcohol
Casual or Family Style Dining Without Alcohol
Fast Food
With Limited Table Service With Alcohol
Restaurant With Alcohol and No Cooking
Is this risk a franchise/chain operation Yes  No
Building Information
Year building was built
Total Square footage of building
Total Square footage of Public Area
Seating Capacity for this location
Construction type of building Frame
Metal
Joisted Masonry
Other
Is there a Fire Extinguishing System over all hoods, ducts and cooking equipment Yes  No
Indicate the type of fully operational fire extinguishing system covering all hoods, ducts and cooking equipment Dry Chemical
UL300
Wet Chemical
Other
None
How often is the system inspected and serviced by a licensed independent contractor
How often are the cooking equipment filters cleaned
Are there any deep fat fryers on the premises
Is the building sprinklered
Type of Alarm System Local Alarm
Central Alarm
None
Hours of Operation
Annual Estimate of Gross Receipts from all food sales at this location *
Annual Estimate of Gross Receipts of Alcohol at this location
Annual Estimate of Gross Receipts from Catering
Is there a dance floor Yes  No
If Yes indicate square footage of dance floor
Bouncers Yes  No
General Liability Limit Desired
Liquor Liability Limit Desired
Liquor License Number
Umbrella Limit Desired
Replacement Cost of Building
Replacement Cost of Contents
Complete This Section for a Workers Compensation Quote:
Number of Employees
Total Annual Gross Payroll for all Employees
Any Work Comp losses in the past three years
cont...
List Officer(s) Names, Title, Job Description and if they want to be included or excluded from work comp coverage
  Officer Name Title Job Description Include (Y/N)
Yes  No
Yes  No
Yes  No
Yes  No
Yes  No
Complete This Section for a Commercial Auto Quote
Vehicle Information
  Year Make Model VIN#
cont...
Driver Information
  Driver Name Date of Birth Drivers License # State Licensed Any Major Violations in the Past 3 years
.
Have there been any commercial auto losses in the last three years
Additional Information
Type any additional information in the box below that you feel may help in obtaining any of the quotes. If you have had any losses in the last three years loss runs may be required before we can offer a firm quote. We may need to contact you if additional information is needed.
* = Required Field
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